{
  "count": 928,
  "note": "GENERATED by SCRIPTS/build_protocol_exports.mjs from cloudflare-pages/for-dentists/protocols/library.json. Do not hand-edit.",
  "protocols": [
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1680 (patient abandonment)",
          "source": "CA B&P §1680 (patient abandonment)"
        },
        {
          "kind": "generic",
          "label": "Coverage roster, patient rescheduling script and internal communication tree — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Coverage roster, patient rescheduling script and internal communication tree: generic functional equivalent"
          },
          "source": "Coverage roster, patient rescheduling script and internal communication tree — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "btc-001",
      "kind": "operational",
      "materials": [
        "schedule export",
        "coverage roster / locum contacts",
        "patient notification script",
        "prescribing continuity list (open scripts, pending refills)",
        "malpractice carrier phone number"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "scheduler",
        "front-desk",
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Office manager gathers what is known: medical emergency, injury, family emergency, expected days vs weeks.\n\nWhy: The response differs sharply for a two-day absence versus a multi-week one.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "short",
              "label": "Expected 1-3 days"
            },
            {
              "goto": "s2",
              "id": "long",
              "label": "Expected more than 3 days / unknown"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Assess the nature and expected length of the absence",
          "why": "The response differs sharply for a two-day absence versus a multi-week one."
        },
        {
          "detail": "Office manager calls the practice owner or, if the absent person is the owner, the designated emergency contact on file, within the first hour of learning of the absence.\n\nWhy: Only the owner or their designee can authorize covering-dentist arrangements and prescribing delegation.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the practice owner (or the absent dentist's designated contact) immediately",
          "why": "Only the owner or their designee can authorize covering-dentist arrangements and prescribing delegation."
        },
        {
          "detail": "A licensed dentist (owner, partner or an on-call covering dentist) reviews what is known about the absence and authorizes the office to pull the affected schedule and begin arranging coverage. This gate authorizes the process to start; it does not itself review the compiled prescription list — that review happens later, immediately before prescribing-continuity decisions are made.\n\nWhy: Prescribing continuity and patient reassignment are clinical decisions that must not be initiated by non-clinical staff alone, even at the process-authorization stage.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off authorizing the office to proceed with schedule triage and coverage arrangements.",
            "role": "practice-owner or covering dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off authorizing the office to proceed with schedule triage and coverage arrangements",
          "why": "Prescribing continuity and patient reassignment are clinical decisions that must not be initiated by non-clinical staff alone, even at the process-authorization stage."
        },
        {
          "detail": "Scheduler exports every booked appointment for the dentist for the expected absence window, sorted by urgency (active pain, post-op checks, new patient exams, routine recall).\n\nWhy: Triage order determines who gets called first and who can safely wait.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull the affected schedule for the absence window",
          "why": "Triage order determines who gets called first and who can safely wait."
        },
        {
          "detail": "Office manager and the licensed reviewer decide whether another in-house dentist absorbs urgent cases, a locum is engaged, or patients are redirected to a specialist/referral network for anything time-sensitive.\n\nWhy: Coverage capacity depends on practice size and whether a second licensed provider is on staff.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "in-house",
              "label": "Another in-house dentist covers urgent cases"
            },
            {
              "goto": "s6",
              "id": "locum",
              "label": "Engage a locum tenens dentist (see btc-016)"
            },
            {
              "goto": "s6",
              "id": "referral-out",
              "label": "Redirect urgent cases to specialist referral network"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide the coverage approach",
          "why": "Coverage capacity depends on practice size and whether a second licensed provider is on staff."
        },
        {
          "detail": "Front desk calls patients flagged urgent within the triage list, offering same-day coverage appointment, specialist referral, or an emergency-guard script (see phone-and-inbound-communication class) if pain is severe.\n\nWhy: Delaying contact with an in-pain patient risks harm and complaint escalation.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact patients with active pain or post-op needs first",
          "why": "Delaying contact with an in-pain patient risks harm and complaint escalation."
        },
        {
          "detail": "Front desk works down the list: call or text each patient, offer the next available slot with any covering dentist or a date after the dentist's expected return, log outcome (rescheduled / cancelled / no response) for each.\n\nWhy: A documented outcome per patient prevents lost appointments and gives the practice a callback list if some patients don't answer.\n\nRecord: reschedule outcome logged per patient in the scheduling system",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Reschedule remaining routine and recall appointments",
          "why": "A documented outcome per patient prevents lost appointments and gives the practice a callback list if some patients don't answer."
        },
        {
          "detail": "The covering or on-call dentist reviews the list of open prescriptions and pending refill requests compiled from the schedule pulled earlier, immediately before deciding what happens to each one.\n\nWhy: This is the consequential clinical-authorization step for prescribing continuity, and must sit directly before the decisions it governs rather than only near the top of the flow.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed review of the compiled prescription list before continuity decisions are made.",
            "role": "covering dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed review of the compiled prescription list before continuity decisions are made",
          "why": "This is the consequential clinical-authorization step for prescribing continuity, and must sit directly before the decisions it governs rather than only near the top of the flow."
        },
        {
          "detail": "The covering or on-call dentist reviews the list of open prescriptions and pending refill requests confirmed at the prescribing-review gate and either continues, modifies, or declines each with a documented clinical reason.\n\nWhy: Patients with active prescriptions (e.g. post-op antibiotics or pain management) cannot be left without a prescriber of record.\n\nRecord: prescribing continuity decisions logged per patient in the clinical record",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Transfer open prescriptions and pending refill requests to the covering dentist",
          "why": "Patients with active prescriptions (e.g. post-op antibiotics or pain management) cannot be left without a prescriber of record."
        },
        {
          "detail": "Office manager sends a brief internal notice (huddle or written) naming who is covering, for how long, and what to tell patients who call.\n\nWhy: Consistent messaging from every staff member prevents conflicting information reaching patients.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief all staff on the coverage plan and expected duration",
          "why": "Consistent messaging from every staff member prevents conflicting information reaching patients."
        },
        {
          "detail": "Office manager checks in once every 24 hours with the absent dentist or their contact for an updated return estimate, and re-runs the schedule triage if the absence extends.\n\nWhy: An absence that was expected to be short can extend; the plan needs to re-trigger triage rather than silently drift.",
          "id": "s11",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 86400,
          "title": "Daily check-in on the absent dentist's status and schedule impact",
          "why": "An absence that was expected to be short can extend; the plan needs to re-trigger triage rather than silently drift."
        },
        {
          "detail": "Based on the daily check-in, decide whether the dentist is returning on the expected date or the absence continues.",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "returning",
              "label": "Dentist confirmed returning within days"
            },
            {
              "goto": "s4",
              "id": "extending",
              "label": "Absence extends beyond original estimate"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "office-manager",
          "title": "Dentist returns or absence extends further"
        },
        {
          "detail": "Office manager provides the returning dentist a summary of who was seen, what was prescribed or deferred, and any patients still needing follow-up.\n\nWhy: The returning dentist needs a clean record of what happened in their absence to resume care safely.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the schedule and continuity notes back to the returning dentist",
          "why": "The returning dentist needs a clean record of what happened in their absence to resume care safely."
        },
        {
          "detail": "Record the absence dates, coverage arrangement used, number of patients affected, and any complaints or clinical follow-ups still open, in the practice's continuity log.\n\nRecord: absence event, coverage method, patient impact count, open follow-ups",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the absence event and outcome"
        },
        {
          "detail": "Absence and coverage cycle closed",
          "id": "s15",
          "kind": "step",
          "role": "office-manager",
          "title": "Absence and coverage cycle closed"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Dentist sudden illness, injury or unplanned absence for days to weeks — The only dentist cannot work for a period of days or weeks — coverage, patient notification and prescribing continuity.",
      "title": "Dentist sudden illness, injury or unplanned absence for days to weeks",
      "trigger": "The only dentist cannot work for a period of days or weeks — coverage, patient notification and prescribing continuity",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §16600 (non-compete unenforceability)",
          "source": "CA B&P §16600 (non-compete unenforceability)"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1680 (patient abandonment)",
          "source": "CA B&P §1680 (patient abandonment)"
        },
        {
          "kind": "statute",
          "label": "CA Labor Code §202 (voluntary resignation with ≥72 hours' notice: final wages due on last day of work; without notice, due within 72 hours) / §203 (waiting-time penalties for late final pay)",
          "repaired": {
            "action": "replace",
            "evidence": "If you voluntarily resign and give at least 72 hours of notice, you must receive your final paycheck on your last day of work; otherwise, your employer has 72 hours to provide it. ... If an employee quits their employment without giving 72 hours previous notice, their wages shall become due and payable not later than 72 hours thereafter.",
            "ticket": "PROT-017",
            "was": {
              "source": "CA Labor Code §201-203 (final wages due immediately on involuntary termination; waiting-time penalties for late final pay)",
              "url": null
            }
          },
          "source": "CA Labor Code §202-203",
          "url": "https://codes.findlaw.com/ca/labor-code/lab-sect-202/"
        },
        {
          "kind": "generic",
          "label": "Exit checklist, patient reassignment script and access revocation sequence — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Exit checklist, patient reassignment script and access revocation sequence: generic functional equivalent"
          },
          "source": "Exit checklist, patient reassignment script and access revocation sequence — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "btc-002",
      "kind": "operational",
      "materials": [
        "employment agreement / non-compete terms",
        "booked schedule export for the departing clinician",
        "patient reassignment plan",
        "exit checklist (keys, credentials, PMS access)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "scheduler",
        "front-desk",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager or owner receives the resignation or delivers the termination, notes the last working day, and logs the date notice was given.\n\nWhy: The clock for reassignment planning starts from a documented last-day date.\n\nRecord: notice date, last working day, reason category (resignation/termination)",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Receive and document the notice",
          "why": "The clock for reassignment planning starts from a documented last-day date."
        },
        {
          "detail": "HR or the practice owner reviews the employment agreement, non-compete terms (noting CA B&P §16600 makes most non-competes unenforceable), final pay obligations, and any confidentiality terms before staff say anything to patients.\n\nWhy: Saying the wrong thing to a departing clinician or to patients before terms are reviewed can create legal exposure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor review of employment terms before any external communication.",
            "role": "practice-owner or HR",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "hr",
          "title": "Supervisor review of employment terms before any external communication",
          "why": "Saying the wrong thing to a departing clinician or to patients before terms are reviewed can create legal exposure."
        },
        {
          "detail": "Scheduler exports all appointments booked with the departing clinician, separating those before the last day (must be kept or reassigned to someone else on staff) from those after (must be reassigned or the patient contacted).\n\nWhy: Any appointment after the last working day cannot simply be left on the books.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull every booked appointment through the last working day and beyond",
          "why": "Any appointment after the last working day cannot simply be left on the books."
        },
        {
          "detail": "Owner decides whether remaining staff absorb the schedule, a replacement is hired, or a locum fills the gap while recruiting.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "absorb",
              "label": "Remaining clinicians absorb the booked patients"
            },
            {
              "goto": "s5",
              "id": "recruit",
              "label": "Begin recruiting a replacement; use locum coverage meanwhile"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide how the vacated production capacity is covered"
        },
        {
          "detail": "Front desk contacts each affected patient: offer the next available appointment with the continuing/new clinician, note any continuity-of-care concerns (e.g. mid-treatment-plan cases), and log the outcome.\n\nWhy: Patients mid-treatment-plan (e.g. an implant case) need explicit continuity handling so care is not interrupted.\n\nRecord: reassignment outcome logged per affected patient",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Reassign patients booked after the last working day",
          "why": "Patients mid-treatment-plan (e.g. an implant case) need explicit continuity handling so care is not interrupted."
        },
        {
          "detail": "The departing clinician (if still on staff during notice period) or the office manager compiles a clinical summary for every patient mid-treatment-plan and hands it to the clinician who will continue care.\n\nWhy: A treatment plan started by one dentist and finished by another needs a documented clinical handoff, not just a rebooked slot.\n\nRecord: treatment continuity summary per in-progress case",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off in-progress treatment plans to the continuing or replacement clinician",
          "why": "A treatment plan started by one dentist and finished by another needs a documented clinical handoff, not just a rebooked slot."
        },
        {
          "detail": "HR/office manager checklist: return of keys and equipment, revoke practice-management-system login and clinical-system access, remove from prescribing/DEA delegation if applicable, collect final timesheet, schedule exit conversation.\n\nWhy: System access left open after departure is a security and compliance gap.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Run the departure exit checklist",
          "why": "System access left open after departure is a security and compliance gap."
        },
        {
          "detail": "IT vendor or office manager confirms practice-management, imaging and clinical-system logins for the departing clinician are disabled, effective no later than end of the last working day.\n\nWhy: Delayed access revocation is one of the most common practice-security gaps after a departure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm all system access is revoked before or on the last working day.",
            "role": "office-manager / it-vendor",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm all system access is revoked before or on the last working day",
          "why": "Delayed access revocation is one of the most common practice-security gaps after a departure."
        },
        {
          "detail": "Office manager briefs the team on who is covering the departing clinician's patients and any temporary schedule changes.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify remaining staff of the change and new coverage arrangement"
        },
        {
          "detail": "Record last working day, patient reassignment completion rate, and access-revocation confirmation in the continuity log.\n\nRecord: departure date, reassignment completion, access revocation confirmation",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the departure event"
        },
        {
          "detail": "Departure transition closed",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Departure transition closed"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Associate dentist or hygienist gives notice with a booked schedule — A producing clinician resigns or is terminated with patients booked weeks out.",
      "title": "Associate dentist or hygienist gives notice with a booked schedule",
      "trigger": "A producing clinician resigns or is terminated with patients booked weeks out",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.508 authorizations for record transfer",
          "source": "HIPAA 45 CFR 164.508 authorizations for record transfer",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "CMS NPPES update within 30 days (45 CFR 162.410); DEA registration address change (21 CFR 1301.51)",
          "source": "CMS NPPES update within 30 days (45 CFR 162.410); DEA registration address change (21 CFR 1301.51)"
        },
        {
          "kind": "generic",
          "label": "90-day transition plan template and staff/patient communication scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "90-day transition plan template and staff/patient communication scripts: generic functional equivalent"
          },
          "source": "90-day transition plan template and staff/patient communication scripts — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 480,
      "frequency": "once",
      "id": "btc-003",
      "kind": "operational",
      "materials": [
        "purchase agreement",
        "patient record custody agreement",
        "staff roster and employment agreements",
        "NPPES/DEA/license registration checklist",
        "90-day transition plan template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "it-vendor",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Buyer's compliance officer confirms: purchase agreement executed, record custody/transfer terms defined, staff offer letters issued, licenses and malpractice coverage active as of closing date.\n\nWhy: Transition day fails if licensing or record-custody terms are not settled before doors open under new ownership.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm pre-closing items are complete",
          "why": "Transition day fails if licensing or record-custody terms are not settled before doors open under new ownership."
        },
        {
          "detail": "Compliance officer confirms the buyer's own dental license, DEA registration (if prescribing), and malpractice coverage are active and valid before the practice opens under new ownership.\n\nWhy: Operating without an active license or DEA registration on transition day is a regulatory violation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before closing-day operations begin.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before closing-day operations begin",
          "why": "Operating without an active license or DEA registration on transition day is a regulatory violation."
        },
        {
          "detail": "Confirm the patient record set (paper and electronic) transfers to the buyer as custodian under the agreement, and that patients have been or will be notified of the change in ownership per the notification protocol (see btc-004 pattern).\n\nWhy: Patient records need a documented custodian at every point; an undocumented gap is a compliance risk.\n\nRecord: record custody transfer confirmation",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Execute record custody transfer per the purchase agreement",
          "why": "Patient records need a documented custodian at every point; an undocumented gap is a compliance risk."
        },
        {
          "detail": "Office manager confirms which existing staff are retained, issues new employment paperwork under the buyer's entity, and briefs the team on new ownership, systems and policies.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm staff retention and re-issue employment agreements"
        },
        {
          "detail": "Within the required windows: update CMS NPPES (within 30 days), DEA registration address/ownership if applicable, state dental board practice ownership record, malpractice carrier, payer/insurance panel notifications, and business licenses.\n\nWhy: Missing a registration update creates billing rejections and compliance exposure that surface weeks later.\n\nRecord: registration update completion per agency, with date",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update regulatory and administrative registrations",
          "why": "Missing a registration update creates billing rejections and compliance exposure that surface weeks later."
        },
        {
          "detail": "IT vendor migrates or re-provisions practice-management system, imaging system, phone lines and website/booking accounts to the buyer's control, revoking seller access.\n\nWhy: Undelivered system access is the most common day-one operational failure in a practice sale.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Transfer practice-management, imaging and phone system access to the buyer",
          "why": "Undelivered system access is the most common day-one operational failure in a practice sale."
        },
        {
          "detail": "Practice sends a welcome letter or notice to active patients introducing new ownership, confirming their provider and records are unchanged in access, and providing updated contact information if it changed.\n\nWhy: Unexplained ownership changes drive patient attrition; a proactive notice reduces it.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Send patient welcome/continuity communication",
          "why": "Unexplained ownership changes drive patient attrition; a proactive notice reduces it."
        },
        {
          "detail": "Owner tracks weekly milestones for the first 90 days: chart audit sample, patient retention check-ins, staff check-ins, financial reconciliation against the purchase agreement's representations.\n\nWhy: Most integration problems (chart gaps, unexpected AR issues, staff attrition) surface within the first quarter and need active tracking, not a one-time checklist.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Track the 90-day transition plan milestones",
          "why": "Most integration problems (chart gaps, unexpected AR issues, staff attrition) surface within the first quarter and need active tracking, not a one-time checklist."
        },
        {
          "detail": "Record patient retention rate, staff retention rate, registration completion status, and any open issues from the purchase agreement's representations.\n\nRecord: 90-day transition outcomes: retention rates, open issues",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Complete the 90-day transition review"
        },
        {
          "detail": "Purchase transition complete",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Purchase transition complete"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Buying a practice — transition day and first 90 days — Closing is scheduled and the buyer takes over patients, staff and records.",
      "title": "Buying a practice — transition day and first 90 days",
      "trigger": "Closing is scheduled and the buyer takes over patients, staff and records",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.530(j) documentation retention; 164.508 authorizations for record transfer",
          "source": "HIPAA 45 CFR 164.530(j) documentation retention; 164.508 authorizations for record transfer",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1680 (patient abandonment)",
          "source": "CA B&P §1680 (patient abandonment)"
        },
        {
          "kind": "generic",
          "label": "Patient notification letter wording and marketing communication plan — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Patient notification letter wording and marketing communication plan: generic functional equivalent"
          },
          "source": "Patient notification letter wording and marketing communication plan — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 300,
      "frequency": "once",
      "id": "btc-004",
      "kind": "operational",
      "materials": [
        "patient notification letter template",
        "record custodian designation",
        "state dental board notice template",
        "active patient list with pending treatment flagged",
        "record retention plan"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "front-desk",
        "marketing",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The practice owner (a licensed dentist) and the compliance officer jointly review the closure/sale/relocation plan — including record custodian designation and continuity arrangements for patients with pending treatment — before any external notice is sent.\n\nWhy: Patient abandonment (CA B&P §1680) exposure and record-custody obligations both attach the moment notice goes out; the plan must be right before it is communicated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed and compliance review before any patient or board notice goes out.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Licensed and compliance review before any patient or board notice goes out",
          "why": "Patient abandonment (CA B&P §1680) exposure and record-custody obligations both attach the moment notice goes out; the plan must be right before it is communicated."
        },
        {
          "detail": "Determine who will hold patient records going forward (buyer, a designated dentist, or a records-management service) for the required retention period, and document the custodian's contact information for patient requests.\n\nWhy: Patients must always have a way to request their records, even after the practice stops operating under its current name.\n\nRecord: record custodian name, contact information, retention period",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Designate the patient record custodian",
          "why": "Patients must always have a way to request their records, even after the practice stops operating under its current name."
        },
        {
          "detail": "Office manager pulls the active patient list and flags anyone mid-treatment-plan (ortho, implants, multi-visit restorative) who needs an individualized continuity plan rather than a form letter.\n\nWhy: A patient mid-implant-case needs specific instructions on who continues their care, not a generic closure notice.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify patients with pending or in-progress treatment",
          "why": "A patient mid-implant-case needs specific instructions on who continues their care, not a generic closure notice."
        },
        {
          "detail": "Compliance officer files the practice closure, sale or relocation notice with the state dental board per its published requirements and timeline.\n\nWhy: Board notification is a regulatory obligation tied to license/practice-location records, independent of patient notice.\n\nRecord: board notice filed, confirmation date",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the required notice with the state dental board",
          "why": "Board notification is a regulatory obligation tied to license/practice-location records, independent of patient notice."
        },
        {
          "detail": "Mail or send the notification letter to all active patients: what is changing (sale/closure/relocation), effective date, where records will be held, and how to request copies or transfer them.\n\nWhy: General patients need clear, timely written notice to make informed choices about continuing care elsewhere.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Send general patient notification letter",
          "why": "General patients need clear, timely written notice to make informed choices about continuing care elsewhere."
        },
        {
          "detail": "Front desk or treatment coordinator personally calls each patient flagged with pending treatment to explain their specific continuity plan (continuing dentist, referral, or completion timeline) before the general notice reaches them.\n\nWhy: A phone call before the form letter prevents a mid-treatment patient from feeling abandoned by mail.\n\nRecord: continuity plan confirmed per pending-treatment patient",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Individually contact patients with pending treatment",
          "why": "A phone call before the form letter prevents a mid-treatment patient from feeling abandoned by mail."
        },
        {
          "detail": "Marketing updates the practice website, directory listings, and appointment booking systems to reflect the closure date, new location, or new ownership so patients don't show up to a closed door.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Update public-facing listings and marketing"
        },
        {
          "detail": "Confirm: all scheduled appointments through the final day are completed or rescheduled, record custody handoff executed, phone line forwarding/voicemail updated with new contact information, signage posted.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the final operating day checklist (closure/relocation only)"
        },
        {
          "detail": "Record the transition type (sale/closure/relocation), effective date, board notice confirmation, custodian designation, and count of patients individually contacted for pending treatment.\n\nRecord: transition type, effective date, board notice, custodian, pending-treatment contact count",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the transition event"
        },
        {
          "detail": "Sale, closure or relocation notice cycle complete",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Sale, closure or relocation notice cycle complete"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Selling, closing or relocating the practice — patient notice, board notice and record custodian — The owner signs a sale agreement, decides to close the doors, or moves the practice.",
      "title": "Selling, closing or relocating the practice — patient notice, board notice and record custodian",
      "trigger": "The owner signs a sale agreement, decides to close the doors, or moves the practice",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "CMS NPPES update within 30 days (45 CFR 162.410); DEA registration address change (21 CFR 1301.51)",
          "source": "CMS NPPES update within 30 days (45 CFR 162.410); DEA registration address change (21 CFR 1301.51)"
        },
        {
          "kind": "generic",
          "label": "New-site build-out sequencing and staff/patient communication plan — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "New-site build-out sequencing and staff/patient communication plan: generic functional equivalent"
          },
          "source": "New-site build-out sequencing and staff/patient communication plan — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 360,
      "frequency": "once",
      "id": "btc-005",
      "kind": "operational",
      "materials": [
        "signed lease",
        "state dental facility permit application",
        "radiation/x-ray equipment registration",
        "NPPES/DEA address update checklist",
        "new location marketing update plan"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "it-vendor",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Compliance officer files the state dental facility permit application, radiation/x-ray equipment registration, and local business license application as soon as the lease is signed.\n\nWhy: Permit approval timelines can run weeks and are frequently the critical-path item for opening day.\n\nRecord: permit applications filed, confirmation numbers",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File required facility and equipment permits",
          "why": "Permit approval timelines can run weeks and are frequently the critical-path item for opening day."
        },
        {
          "detail": "Office manager tracks contractor milestones, equipment delivery and installation (chairs, imaging, sterilization) against the target opening date, flagging slippage early.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Track build-out and equipment installation against opening date"
        },
        {
          "detail": "IT vendor installs and tests the practice-management system, imaging network, and phone/booking lines at the new location before opening day, including a data-connectivity test to any existing sites.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Set up practice-management, imaging and phone systems at the new site"
        },
        {
          "detail": "Update CMS NPPES within the required 30-day window, DEA registration address if prescribing occurs at the new site, malpractice carrier, and payer/insurance panel address records.\n\nWhy: An address mismatch between the physical site and payer records causes claim rejections after opening.\n\nRecord: registration updates completed per agency, with date",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update address-dependent registrations",
          "why": "An address mismatch between the physical site and payer records causes claim rejections after opening."
        },
        {
          "detail": "Compliance officer confirms facility permit, radiation registration, and all required inspections are passed before the first patient is seen at the new location.\n\nWhy: Seeing patients at an unpermitted or uninspected facility is a regulatory violation with license risk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before seeing patients at the new site.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before seeing patients at the new site",
          "why": "Seeing patients at an unpermitted or uninspected facility is a regulatory violation with license risk."
        },
        {
          "detail": "Marketing updates the website, directory listings, and sends a notice to existing patients if this is a relocation, with the new address, parking/access notes, and effective date.",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Announce the new or relocated location"
        },
        {
          "detail": "Confirm: staff scheduled and trained on the new site's layout, supplies stocked, emergency equipment and protocols in place, signage posted, first day's schedule confirmed.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the opening-day readiness checklist"
        },
        {
          "detail": "Record opening date, permit confirmation numbers, registration update completion, and any inspection issues encountered.\n\nRecord: opening date, permits, registrations, inspection notes",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the site opening"
        },
        {
          "detail": "New location opening complete",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "New location opening complete"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Opening a second or relocated office — registrations, permits, notifications and compliance checklist — A lease is signed for a new or replacement site.",
      "title": "Opening a second or relocated office — registrations, permits, notifications and compliance checklist",
      "trigger": "A lease is signed for a new or replacement site",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — construction/renovation infection-control precautions",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — construction/renovation infection-control precautions",
          "url": "https://www.cdc.gov/oral-health/hcp/infection-control/"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice facility standards",
          "source": "Dental Board of California guidance on practice facility standards",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "Infection-control barrier and dust-management plan, reduced-capacity scheduling — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Infection-control barrier and dust-management plan, reduced-capacity scheduling: generic functional equivalent"
          },
          "source": "Infection-control barrier and dust-management plan, reduced-capacity scheduling — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "btc-006",
      "kind": "operational",
      "materials": [
        "construction schedule from contractor",
        "infection-control barrier plan",
        "patient signage/noise advisory",
        "reduced-capacity schedule plan"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "compliance-officer",
        "scheduler",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager reviews the contractor's schedule and identifies which operatories, sterilization areas or common spaces are affected and when, then builds a reduced-capacity patient schedule for the affected weeks.\n\nWhy: Overbooking during construction leads to cancellations and unsafe crowding around active work.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the pre-construction operating plan",
          "why": "Overbooking during construction leads to cancellations and unsafe crowding around active work."
        },
        {
          "detail": "Establish physical barriers (plastic sheeting, negative-pressure setup if available) between construction zones and any clinical or sterilization area, and set a checklist for daily inspection before patients are seen.\n\nWhy: Construction dust near sterilization or open operatories is an infection-control risk that must be actively managed, not assumed away.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Set up infection-control and dust barriers",
          "why": "Construction dust near sterilization or open operatories is an infection-control risk that must be actively managed, not assumed away."
        },
        {
          "detail": "Compliance officer or designated staff member checks the barrier and dust-control setup each morning before the first patient is seen, using the daily checklist.\n\nWhy: A barrier that looked adequate at setup can fail overnight; a daily check catches it before a patient is exposed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance confirms barrier adequacy before patient care resumes each day.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance confirms barrier adequacy before patient care resumes each day",
          "why": "A barrier that looked adequate at setup can fail overnight; a daily check catches it before a patient is exposed."
        },
        {
          "detail": "Front desk or scheduler informs patients when confirming appointments during the construction period about noise, parking or entrance changes, and reschedules anyone uncomfortable with the disruption.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Advise patients of construction noise/access changes"
        },
        {
          "detail": "Office manager briefs staff each week on which areas are active construction zones, safe walking routes, and who to contact if a barrier or safety issue is noticed.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief all staff on daily construction zones and safety routes"
        },
        {
          "detail": "Office manager reviews progress against the contractor's schedule weekly, adjusting the reduced-capacity patient schedule if construction runs long or short.\n\nWhy: Construction schedules slip often enough that the patient schedule needs an active weekly re-check rather than a one-time plan.",
          "id": "s6",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 604800,
          "title": "Weekly review against the construction schedule",
          "why": "Construction schedules slip often enough that the patient schedule needs an active weekly re-check rather than a one-time plan."
        },
        {
          "detail": "Construction complete or continuing",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "complete",
              "label": "Construction finished, area cleared and inspected"
            },
            {
              "goto": "s2",
              "id": "continuing",
              "label": "Construction continues past this week"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Construction complete or continuing"
        },
        {
          "detail": "Office manager confirms the area is clean, inspected and safe, removes temporary barriers, and restores the full patient schedule.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Restore full schedule capacity and remove barriers"
        },
        {
          "detail": "Record construction dates, affected areas, any infection-control incidents, and patient impact.\n\nRecord: construction dates, affected areas, incidents, patient impact",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the construction event"
        },
        {
          "detail": "Construction cycle closed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Construction cycle closed"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Remodel or construction while seeing patients — Contractors begin work in or adjacent to the suite during operating weeks.",
      "title": "Remodel or construction while seeing patients",
      "trigger": "Contractors begin work in or adjacent to the suite during operating weeks",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §16600 (non-compete unenforceability, relevant to any restrictive covenant in the offer)",
          "source": "CA B&P §16600 (non-compete unenforceability, relevant to any restrictive covenant in the offer)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=16600.&lawCode=BPC"
        },
        {
          "kind": "generic",
          "label": "Offer intake, confidentiality handling and advisor-engagement sequence — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Offer intake, confidentiality handling and advisor-engagement sequence: generic functional equivalent"
          },
          "source": "Offer intake, confidentiality handling and advisor-engagement sequence — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "btc-007",
      "kind": "operational",
      "materials": [
        "offer letter/term sheet received",
        "confidentiality checklist",
        "advisor contact list (attorney, CPA, broker)",
        "practice valuation baseline if available"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Practice owner logs the date, sender, and headline terms of the written offer or term sheet.\n\nWhy: A dated record protects the owner if terms are later disputed or the offer is used as leverage elsewhere.\n\nRecord: offer date, sender, headline terms",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Receive and log the offer",
          "why": "A dated record protects the owner if terms are later disputed or the offer is used as leverage elsewhere."
        },
        {
          "detail": "Owner confirms with anyone else on staff who may be contacted by the acquirer that no financial statements, patient counts, or operational data are shared until a mutual confidentiality/NDA agreement is executed.\n\nWhy: Unprotected disclosure of practice financials to a prospective acquirer before an NDA weakens the owner's negotiating position and can leak competitively sensitive information.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm no practice or patient data is shared before a confidentiality agreement is signed",
          "why": "Unprotected disclosure of practice financials to a prospective acquirer before an NDA weakens the owner's negotiating position and can leak competitively sensitive information."
        },
        {
          "detail": "Practice owner decides, alone or with a partner, whether to explore the offer further before any advisor is engaged or data is shared.\n\nWhy: This is a money and ownership-structure decision that stays with the owner — no non-owner staff member should be authorizing next steps.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner decision gate before engaging further.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner decision gate before engaging further",
          "why": "This is a money and ownership-structure decision that stays with the owner — no non-owner staff member should be authorizing next steps."
        },
        {
          "detail": "Decide whether to engage with the offer",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "explore",
              "label": "Engage advisors and explore further"
            },
            {
              "goto": "s9",
              "id": "decline",
              "label": "Decline the offer, no further action"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to engage with the offer"
        },
        {
          "detail": "Owner engages independent legal counsel and a CPA or valuation advisor experienced with practice transitions before sending any substantive response or sharing data.\n\nWhy: Practice sale/DSO terms involve tax, restrictive-covenant and structural complexity that a solo owner should not evaluate alone.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage an attorney and CPA/valuation advisor before responding substantively",
          "why": "Practice sale/DSO terms involve tax, restrictive-covenant and structural complexity that a solo owner should not evaluate alone."
        },
        {
          "detail": "Attorney reviews and the owner executes a mutual NDA with the acquirer before any financial or operational data is shared.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Execute a mutual confidentiality agreement before sharing any data"
        },
        {
          "detail": "Record whether the offer was explored or declined, advisors engaged if any, and NDA execution status.\n\nRecord: offer disposition, advisors engaged, NDA status",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the disposition"
        },
        {
          "detail": "Offer intake cycle closed",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Offer intake cycle closed"
        },
        {
          "detail": "Owner sends a brief written decline, keeping the door open for future contact if desired, without disclosing any practice data.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Send a decline response"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Unsolicited group or acquisition offer received — A group or investor makes a written offer for the practice.",
      "title": "Unsolicited group or acquisition offer received",
      "trigger": "A group or investor makes a written offer for the practice",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §16600 (non-compete unenforceability, relevant if any restrictive covenant surfaces in a buy-out/dissolution path)",
          "source": "CA B&P §16600 (non-compete unenforceability, relevant if any restrictive covenant surfaces in a buy-out/dissolution path)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=16600.&lawCode=BPC"
        },
        {
          "kind": "generic",
          "label": "Governance dispute intake, interim-operations continuity and mediation-referral process — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Governance dispute intake, interim-operations continuity and mediation-referral process: generic functional equivalent"
          },
          "source": "Governance dispute intake, interim-operations continuity and mediation-referral process — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "btc-008",
      "kind": "operational",
      "materials": [
        "partnership/operating agreement",
        "dispute issue log",
        "advisor contact list (attorney, mediator, CPA)",
        "interim operating decisions list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "One or both partners document the core disagreement and specifically what daily operations are affected (e.g. hiring frozen, conflicting schedule decisions, vendor payment delays).\n\nWhy: Separating the underlying disagreement from its operational fallout lets the practice protect patient care while the dispute is resolved.\n\nRecord: dispute summary, operational impact areas",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the dispute and its operational impact",
          "why": "Separating the underlying disagreement from its operational fallout lets the practice protect patient care while the dispute is resolved."
        },
        {
          "detail": "Check the existing agreement for tie-breaking mechanisms, buy-sell provisions, or mandatory mediation/arbitration clauses that already govern this situation.\n\nWhy: Many disputes have an answer already written into the operating agreement that partners overlook in the moment.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the partnership or operating agreement for governance provisions",
          "why": "Many disputes have an answer already written into the operating agreement that partners overlook in the moment."
        },
        {
          "detail": "Both partners (or the managing partner per the operating agreement) agree, at minimum, on interim decisions needed to keep the practice running normally — payroll, vendor payments, scheduling — while the underlying dispute is worked out.\n\nWhy: Patient care and staff pay cannot wait on a resolved partner dispute; an interim operating agreement protects the practice while the bigger issue is worked through.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Agree an interim operating plan before the dispute affects patient care.",
            "role": "practice-owner(s)",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Agree an interim operating plan before the dispute affects patient care",
          "why": "Patient care and staff pay cannot wait on a resolved partner dispute; an interim operating agreement protects the practice while the bigger issue is worked through."
        },
        {
          "detail": "Decide the resolution path",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "direct",
              "label": "Attempt direct resolution between partners"
            },
            {
              "goto": "s10",
              "id": "mediation",
              "label": "Engage a neutral mediator or advisor"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide the resolution path"
        },
        {
          "detail": "Partners meet, ideally with a written agenda of the specific issues logged, and attempt to reach agreement.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Attempt direct resolution"
        },
        {
          "detail": "Was the dispute resolved?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "resolved",
              "label": "Resolved — governance restored"
            },
            {
              "goto": "s11",
              "id": "unresolved",
              "label": "Unresolved — escalate per operating agreement (buy-out, arbitration)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Was the dispute resolved?"
        },
        {
          "detail": "Confirm which interim restrictions are lifted and normal decision-making authority resumes per the operating agreement.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Restore normal operating authority"
        },
        {
          "detail": "Record the resolution path used, outcome, and any changes made to the operating agreement as a result.\n\nRecord: resolution path, outcome, operating agreement changes",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the dispute resolution outcome"
        },
        {
          "detail": "Governance dispute cycle closed",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Governance dispute cycle closed"
        },
        {
          "detail": "Partners jointly engage a neutral third party (mediator, business attorney, or CPA familiar with practice partnerships) to help work through the dispute.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage a neutral mediator, attorney or CPA advisor"
        },
        {
          "detail": "Partners engage the buy-out, arbitration or dissolution mechanism specified in the operating agreement, with legal counsel.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Escalate per the operating agreement's dispute provisions"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Partner dispute or governance deadlock — Co-owners disagree on money, hours, hiring or direction and daily operations begin to suffer.",
      "title": "Partner dispute or governance deadlock",
      "trigger": "Co-owners disagree on money, hours, hiring or direction and daily operations begin to suffer",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "CMS NPPES update within 30 days (45 CFR 162.410)",
          "source": "CMS NPPES update within 30 days (45 CFR 162.410)"
        },
        {
          "kind": "generic",
          "label": "Transition planning, coverage arrangements and communication plans — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Transition planning, coverage arrangements and communication plans: generic functional equivalent"
          },
          "source": "Transition planning, coverage arrangements and communication plans — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 120,
      "frequency": "once",
      "id": "btc-009",
      "kind": "operational",
      "materials": [
        "retirement timeline template",
        "valuation report",
        "patient letter templates",
        "succession candidate list",
        "board/NPPES update checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "dentist",
        "hr",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Owner picks a target date 12–36 months out and records it in the practice transition plan along with the reason (full retirement, partial/phase-down, or sale).\n\nWhy: A named date converts a vague intention into a schedule the rest of the plan can be built backward from.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set and record the target retirement date",
          "why": "A named date converts a vague intention into a schedule the rest of the plan can be built backward from."
        },
        {
          "detail": "Decide whether the practice will be sold to an incoming associate/buyer, transferred to a family successor, or wound down and closed.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "sell",
              "label": "Sell to an internal associate or external buyer"
            },
            {
              "goto": "s13",
              "id": "wind-down",
              "label": "Wind down and close (no buyer)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Choose the transition path"
        },
        {
          "detail": "Commission a practice valuation (production trends, payer mix, lease terms, equipment condition) to set realistic pricing or wind-down expectations.\n\nWhy: Valuation anchors every later negotiation and financing conversation; doing it early avoids a rushed number near the deadline.\n\nRecord: valuation report filed in transition folder",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage a practice valuation",
          "why": "Valuation anchors every later negotiation and financing conversation; doing it early avoids a rushed number near the deadline."
        },
        {
          "detail": "Post the opportunity through professional referral channels, dental society listings, or a broker; screen candidates for clinical fit and cultural fit with staff.\n\nWhy: Generic functional equivalent — practice-transfer brokers and referral networks vary regionally; this step names the function, not a vendor.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Open the successor / buyer search",
          "why": "Generic functional equivalent — practice-transfer brokers and referral networks vary regionally; this step names the function, not a vendor."
        },
        {
          "detail": "Confirm whether a qualified successor/buyer has committed within the planning window.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "found",
              "label": "Yes — proceed to negotiation and staff planning"
            },
            {
              "goto": "s13",
              "id": "not-found",
              "label": "No — extend search or shift to wind-down path"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Successor or buyer identified?"
        },
        {
          "detail": "Identify which staff continue under the successor, draft retention-bonus or transition terms for key employees, and set a timeline for informing the team.\n\nWhy: Staff departures during a transition disrupt patient continuity more than almost anything else; retaining key clinical and front-desk staff protects the practice's value.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Build the staff transition and retention plan",
          "why": "Staff departures during a transition disrupt patient continuity more than almost anything else; retaining key clinical and front-desk staff protects the practice's value."
        },
        {
          "detail": "Owner reviews and approves the transition agreement (or closure decision), verifies the successor's license and credentials directly, and reviews the staff plan before any patient-facing notice goes out.\n\nWhy: Patient notice is not reversible once sent; this is the last checkpoint to confirm terms are final.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before patient notification begins.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before patient notification begins",
          "why": "Patient notice is not reversible once sent; this is the last checkpoint to confirm terms are final."
        },
        {
          "detail": "Mail or hand letters to active patients naming the effective date, the successor dentist (or record custodian if closing), and how to request records; post the notice in the office and on the website.\n\nWhy: Advance patient notice supports the anti-abandonment standard (CA B&P §1680) and gives patients time to arrange continuing care.\n\nRecord: notification date and mailing list logged",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Send patient notification per required lead time",
          "why": "Advance patient notice supports the anti-abandonment standard (CA B&P §1680) and gives patients time to arrange continuing care."
        },
        {
          "detail": "File any required Dental Board notice, update NPPES within 30 days of the effective change (45 CFR 162.410), notify payers/insurance panels, and update DEA registration if location or ownership changes.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Update registrations, board notice and payer records"
        },
        {
          "detail": "Successor dentist (or named record custodian if the practice is closing) receives the active patient chart set and retention plan; confirm retention period meets CA H&S §123145.\n\nWhy: Continuity of care and legal retention duties survive the ownership change even if the seller is gone.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off record custody to the successor or custodian",
          "why": "Continuity of care and legal retention duties survive the ownership change even if the seller is gone."
        },
        {
          "detail": "Track patients re-assigned, staff retained, successor onboarding status, and closing checklist completion in the transition plan document.\n\nRecord: Track patients re-assigned, staff retained, successor onboarding status, and closing checklist completion in the transition plan document.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log transition metrics"
        },
        {
          "detail": "Transition executed and documented",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Transition executed and documented"
        },
        {
          "detail": "Mail or send the closure notification letter to all active patients: effective closure date, where records will be held afterward, and how to request copies or transfer them to a new dentist.\n\nWhy: Patients need clear, timely written notice of closure to make informed choices about continuing care elsewhere and to support the anti-abandonment standard (CA B&P §1680).\n\nRecord: closure notification date and mailing list logged",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify active patients of the wind-down and closure",
          "why": "Patients need clear, timely written notice of closure to make informed choices about continuing care elsewhere and to support the anti-abandonment standard (CA B&P §1680)."
        },
        {
          "detail": "Designate a record custodian (a continuing dentist, records-management service, or the practice owner) to hold the patient chart set for the required retention period, and confirm the retention period meets CA H&S §123145.\n\nWhy: Patient records need a documented custodian and a way for patients to request them even after the practice stops operating.\n\nRecord: record custodian name, contact information, retention period",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off record custody to a designated custodian",
          "why": "Patient records need a documented custodian and a way for patients to request them even after the practice stops operating."
        },
        {
          "detail": "File the practice closure notice with the state dental board, update NPPES within 30 days of the effective closure date (45 CFR 162.410), and notify payers/insurance panels that the practice is closing.",
          "id": "s15",
          "kind": "step",
          "role": "office-manager",
          "title": "File closure notices and update registrations"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Owner retirement — phased transition plan — The owner sets a retirement date 12–36 months out.",
      "title": "Owner retirement — phased transition plan",
      "trigger": "The owner sets a retirement date 12–36 months out",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.530(j) documentation retention; 164.508 authorizations for record transfer",
          "source": "HIPAA 45 CFR 164.530(j) documentation retention; 164.508 authorizations for record transfer",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1680 (patient abandonment)",
          "source": "CA B&P §1680 (patient abandonment)"
        },
        {
          "kind": "generic",
          "label": "Emergency continuity coordination — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Emergency continuity coordination: generic functional equivalent"
          },
          "source": "Emergency continuity coordination — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "btc-010",
      "kind": "operational",
      "materials": [
        "emergency contact/succession binder",
        "power of attorney or estate documents",
        "covering-dentist agreement",
        "patient notification templates",
        "record custodian agreement"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "compliance-officer",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If the owner's incapacity is a live, on-site medical emergency (collapse, cardiac event, unresponsive), call 911 immediately and begin any trained first aid before anything else in this checklist. Only proceed to the continuity steps below once EMS has been engaged or the event is confirmed as already resolved (death, or incapacity confirmed off-site).\n\nWhy: Non-negotiable #5 — emergency response always precedes administrative process; this protocol governs the business-continuity aftermath, not emergency medical response.",
          "gate": {
            "ack": "I confirm I have completed this step as written: If the owner is in active medical distress on-site, call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "If the owner is in active medical distress on-site, call 911 first",
          "why": "Non-negotiable #5 — emergency response always precedes administrative process; this protocol governs the business-continuity aftermath, not emergency medical response."
        },
        {
          "detail": "Confirm the owner's death or incapacity through family, estate representative, or medical confirmation; notify the pre-designated emergency contact (spouse, partner, attorney) named in the practice's continuity binder.\n\nWhy: Verified confirmation before acting protects against premature closure decisions on incomplete information.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the event and notify designated emergency contact",
          "why": "Verified confirmation before acting protects against premature closure decisions on incomplete information."
        },
        {
          "detail": "Pause new scheduling, secure controlled substances and prescription pads, and notify staff arriving for their shift so no patient is seen without a licensed dentist present.\n\nWhy: Treatment cannot legally proceed without a licensed provider; stopping new bookings first prevents a patient arriving to an unstaffed chair.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Secure the practice and cancel same-day risk",
          "why": "Treatment cannot legally proceed without a licensed provider; stopping new bookings first prevents a patient arriving to an unstaffed chair."
        },
        {
          "detail": "Confirm who holds legal authority to act for the practice (executor, power of attorney, surviving partner) before any records are released, staff terminated, or agreements signed.\n\nWhy: Acting without confirmed legal authority can invalidate later decisions and expose the estate and staff to liability.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on legal authority to act.",
            "role": "compliance-officer or estate attorney",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on legal authority to act",
          "why": "Acting without confirmed legal authority can invalidate later decisions and expose the estate and staff to liability."
        },
        {
          "detail": "Determine whether a partner, associate, or pre-arranged covering dentist can take over patient care immediately.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "covering-available",
              "label": "Yes — covering dentist takes over care and scheduling resumes"
            },
            {
              "goto": "s12",
              "id": "no-covering",
              "label": "No — practice will wind down; proceed to closure path"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a covering/successor dentist available to keep the practice open?"
        },
        {
          "detail": "Call or message every patient with an appointment in the next 1–2 weeks to confirm the covering dentist, reschedule, or refer them elsewhere if closing.\n\nWhy: Same standard as any absence protocol — patients cannot be left assuming a cancelled appointment will simply happen.\n\nRecord: outreach log with outcome per patient",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact all patients booked in the near term",
          "why": "Same standard as any absence protocol — patients cannot be left assuming a cancelled appointment will simply happen."
        },
        {
          "detail": "Notify the Dental Board per its practice-closure guidance, update NPPES within 30 days if the practice is closing or changing ownership, and notify DEA if controlled-substance registration is affected.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File required regulatory notifications"
        },
        {
          "detail": "Name a record custodian (covering dentist, successor practice, or a records-storage service) and confirm the retention period meets CA H&S §123145; document how patients can request copies.\n\nWhy: Patient records must remain retrievable for the statutory retention period regardless of what happens to the business entity.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Establish record custody",
          "why": "Patient records must remain retrievable for the statutory retention period regardless of what happens to the business entity."
        },
        {
          "detail": "Inform all staff whether employment continues under a covering dentist/successor or the practice is closing, and process final pay and benefits per applicable labor law if closing.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Notify staff of employment status and next steps"
        },
        {
          "detail": "Log timeline (event confirmed, practice secured, covering dentist engaged, patients notified, board notified, custodian named) in the continuity binder for estate and legal reference.\n\nRecord: Log timeline (event confirmed, practice secured, covering dentist engaged, patients notified, board notified, custodian named) in the continuity binder for estate and legal reference.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the full response"
        },
        {
          "detail": "Continuity response complete",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Continuity response complete"
        },
        {
          "detail": "Because no covering dentist is available, mark this as a closure (not a temporary coverage) event: prepare patient outreach language stating the practice is closing rather than pausing, and flag that the record-custody step ahead must name a permanent, non-practice custodian rather than a returning dentist.\n\nWhy: The wind-down path carries a different patient message and a different record-custody outcome than a temporary-coverage path, even though both share the notification and board-notice mechanics below.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare closure-specific patient and custody messaging",
          "why": "The wind-down path carries a different patient message and a different record-custody outcome than a temporary-coverage path, even though both share the notification and board-notice mechanics below."
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Death or sudden incapacity of the practice owner — records custody and patient continuity — The owner dies or is permanently incapacitated and the practice must keep operating or wind down lawfully.",
      "title": "Death or sudden incapacity of the practice owner — records custody and patient continuity",
      "trigger": "The owner dies or is permanently incapacitated and the practice must keep operating or wind down lawfully",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.530(j) documentation retention; 164.508 authorizations for record transfer",
          "source": "HIPAA 45 CFR 164.530(j) documentation retention; 164.508 authorizations for record transfer",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "CA H&S §123145 (record retention)",
          "source": "CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "System-migration cutover planning and parallel-run practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "System-migration cutover planning and parallel-run practice: generic functional equivalent"
          },
          "source": "System-migration cutover planning and parallel-run practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 180,
      "frequency": "once",
      "id": "btc-011",
      "kind": "operational",
      "materials": [
        "data migration plan",
        "parallel-run schedule",
        "staff training schedule",
        "backup verification checklist",
        "BAA with new vendor"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "it-vendor",
        "compliance-officer",
        "all-staff",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Evaluate candidate practice-management/imaging systems and confirm the selected vendor will sign a Business Associate Agreement before any PHI is shared.\n\nWhy: No PHI may move to a new vendor without a BAA in place per HIPAA — this is a precondition, not a follow-up step.\n\nRecord: signed BAA on file",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Select the new system and confirm BAA",
          "why": "No PHI may move to a new vendor without a BAA in place per HIPAA — this is a precondition, not a follow-up step."
        },
        {
          "detail": "Take a complete backup of the current practice-management database and imaging archive, then verify it restores correctly on a test environment before touching production data.\n\nWhy: A verified backup is the only real rollback option if the migration fails midway.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Full backup and verification of the current system",
          "why": "A verified backup is the only real rollback option if the migration fails midway."
        },
        {
          "detail": "Office manager confirms the backup restore test succeeded before authorizing the migration to continue.\n\nWhy: Skipping backup verification is the single most common cause of unrecoverable data loss in system migrations.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm backup verified before migration proceeds.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm backup verified before migration proceeds",
          "why": "Skipping backup verification is the single most common cause of unrecoverable data loss in system migrations."
        },
        {
          "detail": "Run the vendor's data migration tool to transfer patient demographics, clinical notes, imaging, ledger/billing history, and scheduling data into the new system.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Migrate data to the new system"
        },
        {
          "detail": "Spot-check a sample of patient records, ledger balances, and imaging files in the new system against the old system for accuracy; confirm counts match (patient totals, appointment history, outstanding balances).",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Validate migrated data against source"
        },
        {
          "detail": "Determine whether the spot-check confirms the migration is accurate and complete.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pass",
              "label": "Yes — proceed to staff training and parallel run"
            },
            {
              "goto": "s12",
              "id": "fail",
              "label": "No — halt and remediate with vendor before proceeding"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does validation pass?"
        },
        {
          "detail": "Schedule role-based training sessions (front desk scheduling/billing, clinical charting, imaging) before go-live; confirm each staff member completes it.\n\nWhy: A technically correct migration still fails operationally if staff cannot use the new system on day one.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Train all staff on the new system",
          "why": "A technically correct migration still fails operationally if staff cannot use the new system on day one."
        },
        {
          "detail": "Operate the old and new systems side by side for an agreed period (commonly one to two weeks) to catch discrepancies before fully retiring the old system.\n\nWhy: A parallel run surfaces mismatches while the old system is still available to cross-check, rather than after it is shut down.",
          "id": "s8",
          "kind": "timer",
          "role": "all-staff",
          "timer_seconds": 604800,
          "title": "Run both systems in parallel",
          "why": "A parallel run surfaces mismatches while the old system is still available to cross-check, rather than after it is shut down."
        },
        {
          "detail": "Set a go-live date, stop entering new data in the old system, and make the new system the system of record for scheduling, charting and billing.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Execute cutover to the new system"
        },
        {
          "detail": "Confirm the old system's data is archived (not deleted) and retrievable for the required retention period (CA H&S §123145) before decommissioning access.\n\nRecord: Confirm the old system's data is archived (not deleted) and retrievable for the required retention period (CA H&S §123145) before decommissioning access.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Archive the old system per retention rules"
        },
        {
          "detail": "Migration complete and old system archived",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Migration complete and old system archived"
        },
        {
          "detail": "Stop the migration, document the specific discrepancies found in validation, and work with the vendor to correct the source mapping or re-run the transfer before any further validation is attempted.\n\nWhy: Proceeding to staff training or cutover on unverified or corrupted data (demographics, ledger balances, imaging) risks going live on records that cannot be trusted.",
          "id": "s12",
          "kind": "step",
          "role": "it-vendor",
          "title": "Halt and remediate the migration with the vendor",
          "why": "Proceeding to staff training or cutover on unverified or corrupted data (demographics, ledger balances, imaging) risks going live on records that cannot be trusted."
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Practice-management or imaging system migration — The practice commits to changing its practice-management or imaging software.",
      "title": "Practice-management or imaging system migration",
      "trigger": "The practice commits to changing its practice-management or imaging software",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody (facility relocation notice obligations)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody (facility relocation notice obligations)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "Commercial lease renewal and negotiation practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Commercial lease renewal and negotiation practice: generic functional equivalent"
          },
          "source": "Commercial lease renewal and negotiation practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "btc-012",
      "kind": "operational",
      "materials": [
        "current lease agreement",
        "market rent comparison",
        "attorney contact",
        "relocation contingency checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note the renewal deadline (commonly 6–12 months before expiration per the lease's notice clause) on the practice calendar, or log the date a landlord notice (rent increase, non-renewal, dispute) is received.\n\nWhy: Missing a lease renewal notice window can forfeit renewal rights entirely.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag the lease renewal window or landlord notice",
          "why": "Missing a lease renewal notice window can forfeit renewal rights entirely."
        },
        {
          "detail": "Re-read the lease for renewal option terms, rent escalation clauses, exclusivity/use clauses, and any early-termination or relocation rights.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the current lease terms"
        },
        {
          "detail": "Research comparable commercial rents in the area for similar medical/dental suite space to establish a negotiating baseline.\n\nWhy: Negotiating without a market comparison leaves the practice accepting whatever number the landlord proposes.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather market rent comparison data",
          "why": "Negotiating without a market comparison leaves the practice accepting whatever number the landlord proposes."
        },
        {
          "detail": "Decide whether to renew as offered, negotiate terms, or explore relocation.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "negotiate",
              "label": "Negotiate renewal terms with the landlord"
            },
            {
              "goto": "s10",
              "id": "relocate",
              "label": "Begin exploring relocation options in parallel"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Choose the response path"
        },
        {
          "detail": "Present the market comparison and negotiate rent, term length, tenant improvement allowance, and any dispute resolution if applicable.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Negotiate with the landlord"
        },
        {
          "detail": "Have an attorney review the final lease terms (renewal, new lease, or termination agreement) before signature.\n\nWhy: A multi-year facility commitment carries enough downside that a legal review before signing is standard prudence, not overcaution.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Legal review before signing.",
            "role": "real estate attorney",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Legal review before signing",
          "why": "A multi-year facility commitment carries enough downside that a legal review before signing is standard prudence, not overcaution."
        },
        {
          "detail": "Confirm whether terms were successfully agreed and signed, or the practice is proceeding to relocation.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "signed",
              "label": "Renewed/negotiated and signed"
            },
            {
              "goto": "s8",
              "id": "relocating",
              "label": "Proceeding to relocation — hand off to new-location protocol"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Resolution reached?"
        },
        {
          "detail": "File the executed lease amendment or new lease, and note the outcome and next renewal deadline in the facility file.\n\nRecord: File the executed lease amendment or new lease, and note the outcome and next renewal deadline in the facility file.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the outcome"
        },
        {
          "detail": "Lease matter resolved",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Lease matter resolved"
        },
        {
          "detail": "Research alternative suite space, lease terms and availability while landlord negotiations continue, using the new-location opening checklist (see btc-005) to estimate lead time for permits and registrations at a candidate site.\n\nWhy: A relocation decided at the last minute has no room for the permit and registration lead times a new site requires.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify candidate relocation sites in parallel with negotiation",
          "why": "A relocation decided at the last minute has no room for the permit and registration lead times a new site requires."
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Lease expiration, rent increase or landlord dispute — The lease renewal window opens or the landlord issues a notice.",
      "title": "Lease expiration, rent increase or landlord dispute",
      "trigger": "The lease renewal window opens or the landlord issues a notice",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.530(j) documentation retention (case/shipment record retention)",
          "source": "HIPAA 45 CFR 164.530(j) documentation retention (case/shipment record retention)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "Vendor performance tracking and backup-supplier arrangements — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Vendor performance tracking and backup-supplier arrangements: generic functional equivalent"
          },
          "source": "Vendor performance tracking and backup-supplier arrangements — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "btc-013",
      "kind": "operational",
      "materials": [
        "backup lab/vendor contact list",
        "case tracking log",
        "affected patient list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "dentist",
        "office-manager",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record each late, wrong, or poor-quality case with date, patient case ID (no PHI beyond internal case number), and the specific defect.\n\nWhy: A single bad case can be a fluke; a logged pattern is what justifies switching vendors.",
          "id": "s1",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Identify and log the failure pattern",
          "why": "A single bad case can be a fluke; a logged pattern is what justifies switching vendors."
        },
        {
          "detail": "Distinguish a hard stop (vendor announces closure) from a quality/reliability problem that may be resolvable.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "closing",
              "label": "Vendor is closing — need a full replacement now"
            },
            {
              "goto": "s8",
              "id": "intermittent",
              "label": "Intermittent quality/timing issues — escalate with current vendor first"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the lab/vendor closing entirely or intermittently failing?"
        },
        {
          "detail": "Contact the pre-identified backup lab or vendor, confirm capacity and turnaround, and route new cases there immediately.\n\nWhy: Having a backup vendor identified before a failure happens is what makes this a fast switch instead of a scramble.",
          "id": "s3",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Engage the backup lab/vendor",
          "why": "Having a backup vendor identified before a failure happens is what makes this a fast switch instead of a scramble."
        },
        {
          "detail": "Identify all cases currently with the failing vendor, determine which can be recovered versus must be restarted with the new vendor, and update each affected patient's chair-time schedule.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Reroute active in-progress cases"
        },
        {
          "detail": "Scheduler contacts each patient whose case is delayed to explain the delay in general terms and rebook seating/delivery appointments.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Hand off affected patients to scheduling for rebooking"
        },
        {
          "detail": "Record final outcome (vendor retained, vendor switched, cases recovered) and update the vendor performance file for future decisions.\n\nRecord: Record final outcome (vendor retained, vendor switched, cases recovered) and update the vendor performance file for future decisions.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the resolution and update the vendor file"
        },
        {
          "detail": "Vendor issue resolved",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Vendor issue resolved"
        },
        {
          "detail": "Contact the vendor's account manager with the documented failure log and request a corrective plan and timeline.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Escalate with the current vendor"
        },
        {
          "detail": "Assess whether subsequent cases meet quality and timing standards after escalation.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "corrected",
              "label": "Yes — continue with current vendor, keep monitoring"
            },
            {
              "goto": "s3",
              "id": "not-corrected",
              "label": "No — switch to backup vendor"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Did the vendor correct the issue?"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Dental lab or key vendor closes, misses cases or fails quality — Cases are late or wrong repeatedly, or the lab or vendor announces closure.",
      "title": "Dental lab or key vendor closes, misses cases or fails quality",
      "trigger": "Cases are late or wrong repeatedly, or the lab or vendor announces closure",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody",
          "source": "Dental Board of California guidance on practice closure, sale and record custody",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "CMS NPPES update within 30 days (45 CFR 162.410); DEA registration address change (21 CFR 1301.51)",
          "source": "CMS NPPES update within 30 days (45 CFR 162.410); DEA registration address change (21 CFR 1301.51)"
        },
        {
          "kind": "generic",
          "label": "New-business formation and permitting sequence — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "New-business formation and permitting sequence: generic functional equivalent"
          },
          "source": "New-business formation and permitting sequence — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 480,
      "frequency": "once",
      "id": "btc-014",
      "kind": "operational",
      "materials": [
        "business entity formation documents",
        "NPI/NPPES application",
        "DEA registration application",
        "state dental board practice registration",
        "radiation permit application (if imaging on-site)",
        "malpractice and general liability policy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Register the practice's legal entity (professional corporation, sole proprietorship, or LLC as permitted by state dental practice ownership rules) with the state.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Form the business entity"
        },
        {
          "detail": "Submit the new-practice registration to the state dental board per its guidance on opening a practice, including the responsible licensed dentist's information.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Register the practice location with the state dental board"
        },
        {
          "detail": "Apply for a National Provider Identifier for the practice and provider(s) if not already held, and register the new practice location in NPPES (required update within 30 days of any change, 45 CFR 162.410).",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Obtain NPI and update NPPES"
        },
        {
          "detail": "File a DEA registration or address-change application for the new location before any controlled-substance prescribing occurs there (21 CFR 1301.51).\n\nWhy: Prescribing controlled substances from an unregistered address is a federal violation, not a paperwork formality.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Register DEA registration for the new address",
          "why": "Prescribing controlled substances from an unregistered address is a federal violation, not a paperwork formality."
        },
        {
          "detail": "Determine whether x-ray or CBCT equipment will be installed at the new site.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes-imaging",
              "label": "Yes — apply for the state radiation control permit and equipment inspection"
            },
            {
              "goto": "s7",
              "id": "no-imaging",
              "label": "No on-site imaging planned at open"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Will the practice operate on-site imaging equipment?"
        },
        {
          "detail": "Submit the state radiation control permit application for the x-ray/CBCT equipment and schedule the required equipment inspection before the equipment is used on any patient.\n\nWhy: Operating imaging equipment before the permit and inspection are complete is a regulatory violation, not a paperwork formality.\n\nRecord: radiation permit application filed, inspection scheduled",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the radiation control equipment permit and schedule inspection",
          "why": "Operating imaging equipment before the permit and inspection are complete is a regulatory violation, not a paperwork formality."
        },
        {
          "detail": "Bind malpractice (professional liability) and general/business liability insurance effective on or before the first patient day.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Secure malpractice and general liability coverage"
        },
        {
          "detail": "Adopt a Notice of Privacy Practices, execute BAAs with all vendors touching PHI, and put a records retention and security policy in place before any patient chart is opened.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Stand up HIPAA compliance infrastructure"
        },
        {
          "detail": "Submit credentialing applications to target insurance panels; note this often takes 60–120 days and should start as early as possible against the target open date.\n\nWhy: Payer credentialing is frequently the longest lead-time item in a de-novo startup and is easy to under-schedule.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Begin insurance payer credentialing",
          "why": "Payer credentialing is frequently the longest lead-time item in a de-novo startup and is easy to under-schedule."
        },
        {
          "detail": "Verify state board registration, NPPES, DEA (if prescribing), imaging permit (if applicable), and insurance coverage are all confirmed active before the first patient is scheduled.\n\nWhy: Seeing patients before a required registration is active exposes the practice to regulatory and licensure risk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance confirms all required registrations are in place before opening.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance confirms all required registrations are in place before opening",
          "why": "Seeing patients before a required registration is active exposes the practice to regulatory and licensure risk."
        },
        {
          "detail": "File the completed registration/permit checklist with dates and confirmation numbers in the practice's compliance file.\n\nRecord: File the completed registration/permit checklist with dates and confirmation numbers in the practice's compliance file.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the open-date readiness checklist"
        },
        {
          "detail": "Practice registered and ready to open",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Practice registered and ready to open"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "De novo practice startup: registration and permit sequence — A dentist opens a brand-new practice rather than buying one.",
      "title": "De novo practice startup: registration and permit sequence",
      "trigger": "A dentist opens a brand-new practice rather than buying one",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure and continuity (temporary coverage arrangements)",
          "source": "Dental Board of California guidance on practice closure and continuity (temporary coverage arrangements)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "Disability insurance claim activation and business-overhead-expense claim process — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Disability insurance claim activation and business-overhead-expense claim process: generic functional equivalent"
          },
          "source": "Disability insurance claim activation and business-overhead-expense claim process — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "btc-015",
      "kind": "operational",
      "materials": [
        "disability insurance policy documents",
        "business-overhead-expense policy",
        "physician disability certification form",
        "overhead expense ledger"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Obtain physician documentation of the disability onset date and confirm it against the policy's elimination (waiting) period before benefits begin.\n\nWhy: Benefits do not start until the elimination period is satisfied — filing without tracking this date accurately can delay payment.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm the disability and elimination period start",
          "why": "Benefits do not start until the elimination period is satisfied — filing without tracking this date accurately can delay payment."
        },
        {
          "detail": "Pull the personal disability policy and the separate BOE policy (which reimburses fixed practice overhead — rent, staff payroll, utilities — while the owner cannot work) and confirm coverage terms and required forms.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Review disability and business-overhead-expense (BOE) policies"
        },
        {
          "detail": "Submit the disability claim form with physician certification to the personal disability insurer per its process.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "File the personal disability claim"
        },
        {
          "detail": "Submit the BOE claim with the physician certification plus documentation of ongoing fixed practice expenses (lease, payroll, utilities, loan payments) incurred during the disability period.\n\nWhy: BOE reimburses the practice's fixed costs, not the owner's income — it requires its own separate claim and its own expense documentation.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "File the business-overhead-expense claim",
          "why": "BOE reimburses the practice's fixed costs, not the owner's income — it requires its own separate claim and its own expense documentation."
        },
        {
          "detail": "Maintain a running ledger of covered fixed expenses each month the disability continues, to support ongoing BOE reimbursement claims.",
          "id": "s5",
          "kind": "timer",
          "role": "billing",
          "timer_seconds": 2592000,
          "title": "Track ongoing overhead expenses during the disability period"
        },
        {
          "detail": "Engage a covering or locum dentist (see the locum engagement protocol) so the practice can continue operating and generating revenue during the disability.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange interim clinical coverage"
        },
        {
          "detail": "Confirm claim submissions are accurate and complete before final submission, especially if a representative is filing on the owner's behalf.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner or authorized representative reviews claim status.",
            "role": "practice-owner or designated representative",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner or authorized representative reviews claim status"
        },
        {
          "detail": "Track claim filing dates, elimination period end date, and reimbursement amounts received against the overhead ledger.\n\nRecord: Track claim filing dates, elimination period end date, and reimbursement amounts received against the overhead ledger.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log claim status and reimbursements received"
        },
        {
          "detail": "Disability and BOE claims active and tracked",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Disability and BOE claims active and tracked"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Owner disability: business-overhead-expense and disability insurance claim activation — The owner is disabled beyond the policy elimination period.",
      "title": "Owner disability: business-overhead-expense and disability insurance claim activation",
      "trigger": "The owner is disabled beyond the policy elimination period",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody",
          "source": "Dental Board of California guidance on practice closure, sale and record custody",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "CMS NPPES update within 30 days (45 CFR §162.410) — confirmed. The DEA-registration component is reduced to: locum's DEA registration status should be confirmed active via DEA's official CSA Registration Tools validation service before engagement; no specific CFR section establishes a 'verification' duty, and 21 CFR §1301.51 (cited previously) governs voluntary registration modification, not verification of an existing registration",
          "repaired": {
            "action": "reduce",
            "evidence": "\"45 CFR 162.410(a)(4) require health care providers to notify the NPPES within 30 days of any change in required data elements.\" ... 21 CFR 1301.51(a) allows any registrant to apply to modify their registration to authorize the handling of additional controlled substances or to change their name or address -- a different subject (voluntary modification) from verifying an existing registration's active status, and no CFR section I could find specifically codifies the act of third-party DEA-registration verification as a numbered requirement.",
            "ticket": "PROT-017",
            "was": {
              "source": "CMS NPPES update within 30 days (45 CFR 162.410); DEA registration verification (21 CFR 1301.51)",
              "url": null
            }
          },
          "source": "45 CFR §162.410 (NPPES); DEA CSA Registration Tools validation service (administrative check, no specific CFR provision)"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.530(j) documentation retention",
          "source": "HIPAA 45 CFR 164.530(j) documentation retention",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "Temporary-provider engagement and credentialing checklist — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Temporary-provider engagement and credentialing checklist: generic functional equivalent"
          },
          "source": "Temporary-provider engagement and credentialing checklist — Practice policy — no published authority governs this step."
        }
      ],
      "class": "business-transitions-and-multisite",
      "department": "management",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "btc-016",
      "kind": "operational",
      "materials": [
        "locum agreement/contract template",
        "license and DEA verification checklist",
        "malpractice coverage confirmation",
        "credentialing/privileging checklist",
        "PMS access provisioning form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "hr",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm the absence dates the locum must cover and the scope of procedures the practice needs covered (general, hygiene exams, limited emergency only).",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the coverage need and dates"
        },
        {
          "detail": "Identify a candidate through professional referral networks, locum staffing services, or personal contacts, and confirm availability for the needed dates.\n\nWhy: Generic functional equivalent — locum staffing agencies and referral networks vary regionally; this step names the function, not a vendor.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Source and select a locum dentist",
          "why": "Generic functional equivalent — locum staffing agencies and referral networks vary regionally; this step names the function, not a vendor."
        },
        {
          "detail": "Confirm the locum's state dental license is active and in good standing, DEA registration is valid for the state (or has a valid reciprocity/temporary arrangement), and malpractice insurance is active and covers the engagement dates.\n\nWhy: A gap in any one of these three exposes both the locum and the practice to unlicensed-practice or uncovered-claim risk.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify license, DEA and malpractice coverage",
          "why": "A gap in any one of these three exposes both the locum and the practice to unlicensed-practice or uncovered-claim risk."
        },
        {
          "detail": "Practice owner or a licensed supervising dentist reviews and signs off on the verified license, DEA and malpractice documentation before the locum is scheduled with any patient.\n\nWhy: Never auto-submit a locum to the schedule without a licensed sign-off confirming credentials — this is the consequential clinical-authorization step in the chain.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner/dentist sign-off confirming credentials are verified.",
            "role": "practice-owner or supervising dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner/dentist sign-off confirming credentials are verified",
          "why": "Never auto-submit a locum to the schedule without a licensed sign-off confirming credentials — this is the consequential clinical-authorization step in the chain."
        },
        {
          "detail": "Sign a written agreement covering compensation, scope of duties, hours, malpractice/indemnification terms, and end date.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Execute the locum engagement agreement"
        },
        {
          "detail": "Create a scoped user account in the practice-management system for the locum with access limited to what the engagement requires, expiring on the last covered day.\n\nWhy: Time-limited, scoped access reduces exposure if the account is not manually revoked promptly.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Provision practice-management system access",
          "why": "Time-limited, scoped access reduces exposure if the account is not manually revoked promptly."
        },
        {
          "detail": "Walk the locum through scheduling conventions, emergency protocol, chart documentation standards, and where supplies/instruments are kept before their first patient.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Orient the locum to office procedures"
        },
        {
          "detail": "Determine whether the locum will bill under their own NPI (requiring payer notification) or under the practice's arrangement.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "own-npi",
              "label": "Locum bills under own NPI — notify payers/credentialing as needed"
            },
            {
              "goto": "s9",
              "id": "no-notification",
              "label": "No separate notification required for this arrangement"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the engagement require an NPPES or payer notification?"
        },
        {
          "detail": "Record engagement start date, credential verification date, and PMS access scope in the staffing file.\n\nRecord: Record engagement start date, credential verification date, and PMS access scope in the staffing file.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log engagement start and access provisioned"
        },
        {
          "detail": "Deactivate the locum's PMS access within 24 hours of their last covered day and hand off any pending treatment notes or follow-ups to the returning or covering dentist.\n\nWhy: Prompt access revocation closes the exposure window created by the temporary account.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Revoke access and hand off any open items at engagement end",
          "why": "Prompt access revocation closes the exposure window created by the temporary account."
        },
        {
          "detail": "Locum engagement completed and closed out",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Locum engagement completed and closed out"
        }
      ],
      "subclass": "business-transitions-and-continuity",
      "summary": "Locum tenens dentist engagement checklist — A temporary dentist is engaged to cover an absence.",
      "title": "Locum tenens dentist engagement checklist",
      "trigger": "A temporary dentist is engaged to cover an absence",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "source": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "url": "https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB3030"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "caai-001",
      "kind": "compliance",
      "materials": [
        "AI drafting tool with disclosure template",
        "clinical review queue",
        "disclosure text library"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "it-vendor",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Before sending, confirm whether the message was drafted or generated by an AI tool and whether it touches diagnosis, treatment, symptoms, medications or clinical instructions.\n\nWhy: AB 3030 only reaches AI-generated communications with clinical content — routine appointment reminders and billing notices are out of scope.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the message as AI-generated and clinical in content",
          "why": "AB 3030 only reaches AI-generated communications with clinical content — routine appointment reminders and billing notices are out of scope."
        },
        {
          "detail": "Route based on whether the draft discusses diagnosis, treatment, symptoms, medication, or clinical follow-up instructions.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "Yes — clinical content present"
            },
            {
              "goto": "s8",
              "id": "no",
              "label": "No — administrative/scheduling only"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the message contain clinical content?"
        },
        {
          "detail": "For an occasional written communication (email, portal message, letter): insert the standard disclosure — \"This message was drafted with AI assistance and has been reviewed by a licensed provider\" (AB 3030 pattern) — once, at the top or bottom of the message, above the send button. For a chatbot or other continuous chat-based interaction: display the disclosure as a persistent, always-visible element for the full session, not a one-time insertion.\n\nWhy: H&S §1339.75(a) distinguishes occasional written communications, where the disclaimer runs once at the start, from continuous chat interactions, which require the disclaimer displayed prominently throughout — a single top/bottom line satisfies the first but not the second.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Attach the AB 3030 disclosure appropriate to the channel",
          "why": "H&S §1339.75(a) distinguishes occasional written communications, where the disclaimer runs once at the start, from continuous chat interactions, which require the disclaimer displayed prominently throughout — a single top/bottom line satisfies the first but not the second."
        },
        {
          "detail": "The dentist or hygienist reads the AI-drafted content for accuracy, edits as needed, and confirms it is ready to send.\n\nWhy: Under AB 3030, a genuine licensed review of AI-generated content is what makes the disclosure requirement optional in the first place (H&S §1339.75(a): 'the requirements... do not apply' once reviewed) — the practice keeps both the disclosure AND this review as defense-in-depth HITL policy, not because the statute layers review on top of the disclosure requirement.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider reviews and edits the draft before send.",
            "role": "dentist or hygienist of record",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider reviews and edits the draft before send",
          "why": "Under AB 3030, a genuine licensed review of AI-generated content is what makes the disclosure requirement optional in the first place (H&S §1339.75(a): 'the requirements... do not apply' once reviewed) — the practice keeps both the disclosure AND this review as defense-in-depth HITL policy, not because the statute layers review on top of the disclosure requirement."
        },
        {
          "detail": "Record which message, which AI tool, the reviewing provider, and the date/time of review in the practice's compliance log.\n\nRecord: AB 3030 review log entry: message type, AI tool used, reviewing provider, timestamp",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the disclosure and review in the compliance record"
        },
        {
          "detail": "Send the message only after both the disclosure line and provider review are confirmed present.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the disclosed, reviewed message to the patient"
        },
        {
          "detail": "Disclosure workflow complete",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Disclosure workflow complete"
        },
        {
          "detail": "Administrative and scheduling-only AI-drafted messages do not require the AB 3030 clinical disclosure; send normally.\n\nRecord: No compliance action required — message classified administrative, not clinical",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Send administrative message without AB 3030 disclosure"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "AB 3030 disclosure on AI-generated written, portal, email or chat clinical communications — A patient portal message, email, post-op follow-up or chatbot reply with clinical content is generated by an AI tool.",
      "title": "AB 3030 disclosure on AI-generated written, portal, email or chat clinical communications",
      "trigger": "A patient portal message, email, post-op follow-up or chatbot reply with clinical content is generated by an AI tool",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "source": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "url": "https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB3030"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 3,
      "frequency": "per-use",
      "id": "caai-002",
      "kind": "compliance",
      "materials": [
        "AI voice agent script with disclosure line",
        "call log system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "compliance-officer",
        "it-vendor",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The AI agent system places an outbound call to a patient, or answers an inbound patient call or video session, on a clinical matter.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "AI voice or video agent initiates or answers a clinical call"
        },
        {
          "detail": "Outbound calls are dialed with a known clinical purpose already established; inbound calls and video sessions begin with the patient's reason unknown to the agent.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "outbound",
              "label": "Outbound — purpose known before dialing"
            },
            {
              "goto": "s4",
              "id": "inbound",
              "label": "Inbound call or video — patient's reason not yet known"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Is this an outbound call or an inbound call/video session?"
        },
        {
          "detail": "Route based on whether the call topic is clinical (symptoms, treatment, medication, follow-up care) versus purely administrative (confirming an address).",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — clinical topic"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "No — purely administrative"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Is the call about a clinical matter?"
        },
        {
          "detail": "An inbound call discloses immediately on answer, before asking the reason for the call, because the topic cannot be classified before the patient speaks; an outbound call already knows the topic and discloses next. Voice and video then diverge on how the disclosure is presented.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "voice",
              "label": "Voice-only call"
            },
            {
              "goto": "s13",
              "id": "video",
              "label": "Video session"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Is this a voice-only call or a video session?"
        },
        {
          "detail": "The agent opens with a spoken disclosure — \"You are speaking with an AI assistant; your provider will review anything clinical before it is finalized\" (AB 3030 pattern) — before discussing any clinical content. For an inbound call this is spoken immediately on answer, before asking why the patient is calling.\n\nWhy: AB 3030 requires the disclosure to be given to the patient, and a verbal channel requires a verbal disclosure, not just a written one on file.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "State the AI disclosure aloud before any clinical content",
          "why": "AB 3030 requires the disclosure to be given to the patient, and a verbal channel requires a verbal disclosure, not just a written one on file."
        },
        {
          "detail": "State that the patient may ask to speak with a staff member at any point in the call, and honor that request immediately if made.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Offer a path to a live staff member on request"
        },
        {
          "detail": "Continue with the AI agent, or transfer to a live staff member if the patient asks.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "continue",
              "label": "Patient continues with AI agent"
            },
            {
              "goto": "s14",
              "id": "transfer",
              "label": "Patient requests a human"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient accept the AI-assisted call?"
        },
        {
          "detail": "Confirm the call log shows the opening disclosure line was spoken (or, for video, displayed throughout) and the escalation offer was made before any clinical content.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the disclosure and escalation offer were logged.",
            "role": "compliance officer or designated reviewer",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm the disclosure and escalation offer were logged"
        },
        {
          "detail": "Before disconnecting, state again — \"You have been speaking with an AI assistant; anything clinical will be reviewed by your provider\" — as the required closing disclosure, or for video keep the overlay visible through disconnect.\n\nWhy: H&S §1339.75(a) requires the audio disclosure at both the start and the end of the interaction; closing the call without repeating it leaves the interaction out of compliance even when the opening disclosure was given.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Repeat the AI disclosure aloud before the call ends",
          "why": "H&S §1339.75(a) requires the audio disclosure at both the start and the end of the interaction; closing the call without repeating it leaves the interaction out of compliance even when the opening disclosure was given."
        },
        {
          "detail": "Record the call date/time, AI tool used, channel (voice/video), opening disclosure given (yes/no), closing disclosure given (yes/no), and whether escalation was offered.\n\nRecord: AB 3030 voice/video disclosure log entry: opening and closing disclosure both confirmed",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the disclosed AI voice interaction"
        },
        {
          "detail": "Voice/video disclosure workflow complete",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Voice/video disclosure workflow complete"
        },
        {
          "detail": "Purely administrative AI calls do not require the AB 3030 clinical disclosure; continue the call normally.\n\nRecord: No compliance action required — call classified administrative, not clinical",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Continue administrative AI call without clinical disclosure"
        },
        {
          "detail": "Show a visible on-screen disclaimer — \"You are speaking with an AI assistant; your provider will review anything clinical before it is finalized\" (AB 3030 pattern) — that remains displayed throughout the video session, not just at the start.\n\nWhy: AB 3030 requires video communications to display the disclaimer prominently throughout the interaction, a persistent overlay rather than a single spoken line.",
          "id": "s13",
          "kind": "step",
          "role": "it-vendor",
          "title": "Display a persistent AI disclosure overlay for the full video session",
          "why": "AB 3030 requires video communications to display the disclaimer prominently throughout the interaction, a persistent overlay rather than a single spoken line."
        },
        {
          "detail": "Before handing off, state again — \"You have been speaking with an AI assistant; a staff member is joining now\" — closing out the AI-assisted portion of the call with the required closing disclosure.\n\nWhy: H&S §1339.75(a) requires the audio disclosure at both the start and the end of the AI-assisted interaction, including when the call ends by transfer rather than by hanging up.",
          "id": "s14",
          "kind": "step",
          "role": "it-vendor",
          "title": "Repeat the AI disclosure aloud before transferring",
          "why": "H&S §1339.75(a) requires the audio disclosure at both the start and the end of the AI-assisted interaction, including when the call ends by transfer rather than by hanging up."
        },
        {
          "detail": "Front desk receives the call, greets the patient, and continues the conversation without the AI agent.",
          "id": "s15",
          "kind": "step",
          "role": "front-desk",
          "title": "Transfer the call to a live front-desk staff member"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "AB 3030 verbal disclosure on AI-generated voice or video patient communications — An AI voice agent calls or answers a patient about a clinical matter.",
      "title": "AB 3030 verbal disclosure on AI-generated voice or video patient communications",
      "trigger": "An AI voice agent calls or answers a patient about a clinical matter",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "source": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "url": "https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB3030"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "caai-003",
      "kind": "compliance",
      "materials": [
        "AI draft queue",
        "review log template",
        "the practice's disclosure text library"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The AI-drafted message, letter or instruction is placed in the licensed-review queue rather than sent directly to the patient.\n\nWhy: AB 3030's provider-reviewed exemption requires a genuine licensed review before the message reaches the patient — nothing auto-sends.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "AI-drafted patient communication is queued for review",
          "why": "AB 3030's provider-reviewed exemption requires a genuine licensed review before the message reaches the patient — nothing auto-sends."
        },
        {
          "detail": "The dentist or hygienist reads the AI-generated content in full and compares it against the patient's actual clinical situation as documented in the chart.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Reviewing clinician reads the full draft against the chart"
        },
        {
          "detail": "Decide whether the AI draft is accurate as written or needs correction before it can be sent.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "edit",
              "label": "Edit the draft for accuracy"
            },
            {
              "goto": "s5",
              "id": "asis",
              "label": "Approve as written"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the draft need edits?"
        },
        {
          "detail": "Correct any inaccurate, incomplete, or unclear clinical content in the draft before continuing.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Edit the draft directly"
        },
        {
          "detail": "The reviewing dentist or hygienist confirms the draft is accurate and ready to send under the provider-reviewed exemption.\n\nWhy: The signoff is the exemption's substance — a named licensed reviewer taking responsibility for what is sent, not a checkbox.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed clinician signs off on the reviewed draft.",
            "role": "reviewing dentist or hygienist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed clinician signs off on the reviewed draft",
          "why": "The signoff is the exemption's substance — a named licensed reviewer taking responsibility for what is sent, not a checkbox."
        },
        {
          "detail": "Log the reviewer's name and license, the date/time of review, whether edits were made, and confirmation the AB 3030 disclosure line is attached.\n\nRecord: Provider-reviewed exemption log: reviewer, timestamp, edited (yes/no), disclosure attached (yes/no)",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the review log entry"
        },
        {
          "detail": "Move the reviewed and logged draft out of the review queue so front desk can send it.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Release the message for sending"
        },
        {
          "detail": "Provider-reviewed exemption workflow complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Provider-reviewed exemption workflow complete"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "Provider-reviewed exemption — licensed review of AI drafts before sending, with review log — A clinician reviews and edits an AI-drafted patient message, letter or instruction before it is sent.",
      "title": "Provider-reviewed exemption — licensed review of AI drafts before sending, with review log",
      "trigger": "A clinician reviews and edits an AI-drafted patient message, letter or instruction before it is sent",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Penal Code §632 (confidential communication recording consent)",
          "source": "California Penal Code §632 (confidential communication recording consent)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=632."
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 3,
      "frequency": "per-use",
      "id": "caai-004",
      "kind": "compliance",
      "materials": [
        "phone system with recording announcement configured",
        "opt-out procedure card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm which phone lines or call types (all calls, or only calls transferred to a recorded queue) have recording enabled.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Phone system recording feature is turned on for a line"
        },
        {
          "detail": "The phone system plays or the staff member states, at the start of the call, \"This call may be recorded for quality and training purposes\" before any confidential clinical or billing content is discussed. If the caller is a minor patient calling without a parent or guardian on the line, obtain the parent/guardian's consent instead (see the ambient-scribe and telehealth protocols' minor/guardian consent branch for the fuller pattern).\n\nWhy: California Penal Code §632 requires all parties to a confidential communication to consent before recording begins — the announcement must come first, not after.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Play the recording announcement before the substantive call begins.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "front-desk",
          "title": "Play the recording announcement before the substantive call begins",
          "why": "California Penal Code §632 requires all parties to a confidential communication to consent before recording begins — the announcement must come first, not after."
        },
        {
          "detail": "Listen for any objection to the recording announcement.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-objection",
              "label": "No objection — proceed recorded"
            },
            {
              "goto": "s7",
              "id": "objects",
              "label": "Caller objects to recording"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "patient",
          "title": "Does the caller object to being recorded?"
        },
        {
          "detail": "Proceed with the call normally, with recording active for the duration.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Continue the call with recording active"
        },
        {
          "detail": "Record the date, call type, whether the announcement was played, and whether the caller consented or objected.\n\nRecord: Recording consent log entry: date, announcement played (yes/no), caller response",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the consent outcome"
        },
        {
          "detail": "Call recording consent workflow complete",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Call recording consent workflow complete"
        },
        {
          "detail": "Disable recording for this specific call, or transfer to a non-recorded line, and continue the conversation.\n\nWhy: Continuing to record after an objection removes the consent §632 requires.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Stop or bypass recording for this call",
          "why": "Continuing to record after an objection removes the consent §632 requires."
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "Phone call recording announcement and all-party consent capture — Call recording is enabled on the phone system, or a recorded call begins.",
      "title": "Phone call recording announcement and all-party consent capture",
      "trigger": "Call recording is enabled on the phone system, or a recorded call begins",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Penal Code §632 (confidential communication recording consent)",
          "source": "California Penal Code §632 (confidential communication recording consent)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=632."
        },
        {
          "kind": "regulation",
          "label": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "source": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.504"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "caai-005",
      "kind": "compliance",
      "materials": [
        "ambient scribe consent script/card",
        "scribe tool configured for zero raw-audio retention"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant",
        "patient",
        "caregiver",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Before starting the appointment, the dentist or hygienist decides to use the ambient documentation tool to draft chart notes.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Clinician proposes using the ambient scribe for this appointment"
        },
        {
          "detail": "Tell the patient the appointment audio will be listened to by an AI tool to draft clinical notes, that raw audio is not kept after transcription, and that the note will be reviewed by the clinician.\n\nWhy: The patient needs to understand what is being recorded and how it is handled before consent can be meaningful under §632.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Explain the ambient scribe to the patient",
          "why": "The patient needs to understand what is being recorded and how it is handled before consent can be meaningful under §632."
        },
        {
          "detail": "Route consent to the patient directly, or to the accompanying parent/guardian, based on whether the patient is a minor.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "adult",
              "label": "Adult patient"
            },
            {
              "goto": "s10",
              "id": "minor",
              "label": "Minor patient — guardian must consent"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the patient a minor?"
        },
        {
          "detail": "Ask the patient directly whether they consent to the ambient scribe recording this appointment, and wait for an affirmative answer before starting the tool.\n\nWhy: California Penal Code §632 requires all-party consent before a confidential in-office conversation is recorded, even for a documentation tool.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain the patient's spoken or written consent before recording.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain the patient's spoken or written consent before recording",
          "why": "California Penal Code §632 requires all-party consent before a confidential in-office conversation is recorded, even for a documentation tool."
        },
        {
          "detail": "Route based on the patient's answer to the consent request.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "Patient consents"
            },
            {
              "goto": "s11",
              "id": "no",
              "label": "Patient declines"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient consent?"
        },
        {
          "detail": "Enable the tool for this appointment only, confirmed configured for no raw-audio retention beyond the transcription step.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Start the ambient scribe tool for the appointment"
        },
        {
          "detail": "The dentist or hygienist reads the scribe-drafted note in full, corrects it, and signs it before it becomes part of the permanent chart.\n\nWhy: The note carries clinical weight in the chart, so a licensed reviewer must confirm it before it is finalized — never auto-filed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Clinician reviews the AI-drafted note before it enters the chart.",
            "role": "dentist or hygienist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Clinician reviews the AI-drafted note before it enters the chart",
          "why": "The note carries clinical weight in the chart, so a licensed reviewer must confirm it before it is finalized — never auto-filed."
        },
        {
          "detail": "Record the appointment date, patient consent (yes/no), tool used, and confirmation that raw audio was not retained.\n\nRecord: Ambient scribe consent log entry: date, consent given, tool, retention confirmed",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the scribe consent and retention confirmation"
        },
        {
          "detail": "Ambient scribe consent workflow complete",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Ambient scribe consent workflow complete"
        },
        {
          "detail": "Ask the accompanying parent or guardian directly whether they consent to the ambient scribe recording this appointment on behalf of the minor patient, and wait for an affirmative answer before starting the tool.\n\nWhy: A minor patient cannot meaningfully consent to an audio recording under §632 practice; the parent or guardian of record must consent instead.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain the accompanying parent/guardian's consent before recording.",
            "type": "safety"
          },
          "id": "s10",
          "kind": "gate",
          "role": "caregiver",
          "title": "Obtain the accompanying parent/guardian's consent before recording",
          "why": "A minor patient cannot meaningfully consent to an audio recording under §632 practice; the parent or guardian of record must consent instead."
        },
        {
          "detail": "The clinician writes chart notes by hand or dictates without the ambient tool, per the practice's standard charting process.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the appointment manually instead"
        },
        {
          "detail": "Record the appointment date and that the patient declined the ambient scribe, so decline counts are tracked the same way consents are.\n\nRecord: Ambient scribe decline log entry: date, patient declined, manual notes used",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the scribe decline"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "Ambient scribe or in-operatory audio consent before recording, with no raw-audio retention — A clinician wants to use an ambient documentation tool or voice scribe during an appointment.",
      "title": "Ambient scribe or in-operatory audio consent before recording, with no raw-audio retention",
      "trigger": "A clinician wants to use an ambient documentation tool or voice scribe during an appointment",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Penal Code §632 (confidential communication recording consent)",
          "source": "California Penal Code §632 (confidential communication recording consent)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=632."
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 3,
      "frequency": "per-patient",
      "id": "caai-006",
      "kind": "compliance",
      "materials": [
        "telehealth platform with recording toggle",
        "consent script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the telehealth platform for this session has a recording feature that could be enabled.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Telehealth session is scheduled with recording available"
        },
        {
          "detail": "Check that recording is off by default for the session and will only be turned on if the clinician deliberately enables it.\n\nWhy: A no-record default avoids inadvertent recording without consent, which is the safer starting position under §632.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the platform's default is no-record",
          "why": "A no-record default avoids inadvertent recording without consent, which is the safer starting position under §632."
        },
        {
          "detail": "Decide whether there is a documentation or teaching reason to record this specific session.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no",
              "label": "No — leave unrecorded (default)"
            },
            {
              "goto": "s7",
              "id": "yes",
              "label": "Yes — record this session"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the clinician want to record this session?"
        },
        {
          "detail": "Begin the telehealth consult with recording off, per the platform default or the patient's decline.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Start the session without recording"
        },
        {
          "detail": "Record the session date and the reason recording did not happen — platform default, or the patient declined — so no-record rates can be tracked.\n\nRecord: Telehealth no-record log entry: date, reason (default or decline)",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the no-record outcome"
        },
        {
          "detail": "Telehealth recording consent workflow complete",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Telehealth recording consent workflow complete"
        },
        {
          "detail": "Route consent to the patient directly, or to the accompanying parent/guardian joining the telehealth session, based on whether the patient is a minor.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "adult",
              "label": "Adult patient"
            },
            {
              "goto": "s12",
              "id": "minor",
              "label": "Minor patient — guardian must consent"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the patient a minor?"
        },
        {
          "detail": "Before enabling recording, tell the patient the session will be recorded and why, and wait for their explicit agreement.\n\nWhy: California Penal Code §632 requires all-party consent before recording a confidential telehealth conversation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain the patient's consent before starting to record.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain the patient's consent before starting to record",
          "why": "California Penal Code §632 requires all-party consent before recording a confidential telehealth conversation."
        },
        {
          "detail": "Route based on the patient's response to the recording request.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "yes",
              "label": "Patient consents"
            },
            {
              "goto": "s4",
              "id": "no",
              "label": "Patient declines"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient consent to recording?"
        },
        {
          "detail": "Turn on recording only after consent is confirmed, then proceed with the telehealth consult.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Enable recording and proceed with the session"
        },
        {
          "detail": "Record that consent was given, the date, and store the recording per the practice's retention schedule.\n\nRecord: Telehealth recording consent log entry: date, consent given, retention period applied",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Log consent and apply the retention policy"
        },
        {
          "detail": "Before enabling recording, tell the parent or guardian joining the pediatric telehealth session that it will be recorded and why, and wait for their explicit agreement.\n\nWhy: A minor patient cannot meaningfully consent to a telehealth recording under §632 practice; the parent or guardian of record must consent instead.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain the accompanying parent/guardian's consent before starting to record.",
            "type": "safety"
          },
          "id": "s12",
          "kind": "gate",
          "role": "caregiver",
          "title": "Obtain the accompanying parent/guardian's consent before starting to record",
          "why": "A minor patient cannot meaningfully consent to a telehealth recording under §632 practice; the parent or guardian of record must consent instead."
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "Telehealth session recording consent or no-record default — A video consult is about to start and recording is available.",
      "title": "Telehealth session recording consent or no-record default",
      "trigger": "A video consult is about to start and recording is available",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Penal Code §632 (confidential communication recording consent)",
          "source": "California Penal Code §632 (confidential communication recording consent)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=632."
        },
        {
          "kind": "statute",
          "label": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "source": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "url": "https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB3030"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 3,
      "frequency": "as-needed",
      "id": "caai-007",
      "kind": "compliance",
      "materials": [
        "chart flag/preference field",
        "opt-out log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Listen to the patient's stated preference and confirm what specifically they are declining — recording, AI-drafted messages, or both.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient states they do not want to be recorded or receive AI-generated messages"
        },
        {
          "detail": "Ask whether the decline applies to phone recording, ambient scribe recording, AI-drafted messages, or all of these, and note the answer.\n\nWhy: A patient may decline one channel but be fine with another; assuming a blanket opt-out without asking risks over-restricting care communication.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the scope of the decline with the patient",
          "why": "A patient may decline one channel but be fine with another; assuming a blanket opt-out without asking risks over-restricting care communication."
        },
        {
          "detail": "If a recording or AI-assisted process is in progress, stop it right away — do not wait for the current interaction to finish.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Stop the declined activity immediately"
        },
        {
          "detail": "Set a visible preference flag in the patient's record noting the declined channel(s) so future staff and systems see it before recording or using AI drafting.\n\nRecord: Patient communication preference flag: declined channel(s), date set",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the preference in the patient's chart"
        },
        {
          "detail": "Alert front desk, clinical staff, and the compliance officer that this patient has an active opt-out so it is honored across future visits and channels.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify relevant staff of the patient's preference"
        },
        {
          "detail": "Provide the same service through the manual alternative — human-written messages, non-recorded calls, or hand-charted notes — with no reduction in the quality of care or communication.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Offer the equivalent non-AI or non-recorded process"
        },
        {
          "detail": "Patient decline handled and preference on file",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Patient decline handled and preference on file"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "Patient declines recording or AI-assisted communication — A patient says they do not want to be recorded or to receive AI-generated messages.",
      "title": "Patient declines recording or AI-assisted communication",
      "trigger": "A patient says they do not want to be recorded or to receive AI-generated messages",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "source": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.504"
        },
        {
          "kind": "statute",
          "label": "California CMIA Civil Code §56.10 (medical information handling by contracted vendors)",
          "source": "California CMIA Civil Code §56.10 (medical information handling by contracted vendors)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=56.10."
        },
        {
          "kind": "statute",
          "label": "California CCPA Civil Code §1798.100 et seq. (where thresholds apply)",
          "source": "California CCPA Civil Code §1798.100 et seq. (where thresholds apply)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=1798.100."
        },
        {
          "kind": "statute",
          "label": "California breach notice Civil Code §1798.82",
          "source": "California breach notice Civil Code §1798.82",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=1798.82."
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "caai-008",
      "kind": "compliance",
      "materials": [
        "approved AI tool list",
        "business associate agreement template",
        "staff instruction memo"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "it-vendor",
        "practice-owner",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The staff member raises the request with the office manager or compliance officer instead of using the tool directly with patient information.\n\nWhy: The default must be to ask before using any AI tool with PHI, not to use it and ask forgiveness.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "A staff member wants to use an AI tool with patient information, or proposes a new AI vendor",
          "why": "The default must be to ask before using any AI tool with PHI, not to use it and ask forgiveness."
        },
        {
          "detail": "Check the current approved AI tool list to see whether this specific tool already has a signed business associate agreement on file.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "approved",
              "label": "Yes — already approved with BAA"
            },
            {
              "goto": "s6",
              "id": "not-approved",
              "label": "No — not on the list"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is this tool already on the approved list with a signed BAA?"
        },
        {
          "detail": "Use the approved AI tool only within the scope recorded on the approved list, and only for the use case reviewed.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Use the approved tool within its authorized scope"
        },
        {
          "detail": "Send or post a reminder memo to all staff naming the current approved tool list and restating that PHI never goes into an unlisted AI tool.\n\nWhy: The wall only holds if every staff member is reminded which tools are approved, since the list changes as vendors are added or removed.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Reissue the staff instruction memo on the no-PHI-to-unlisted-tools wall",
          "why": "The wall only holds if every staff member is reminded which tools are approved, since the list changes as vendors are added or removed."
        },
        {
          "detail": "AI tool vendor wall workflow complete",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "AI tool vendor wall workflow complete"
        },
        {
          "detail": "Instruct the staff member not to paste chart notes, images or any patient identifiers into the unlisted tool until it clears review.\n\nWhy: An AI vendor without a signed BAA is not authorized to receive PHI — this is the wall the protocol exists to enforce.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Block any PHI use of the unlisted tool pending review.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Block any PHI use of the unlisted tool pending review",
          "why": "An AI vendor without a signed BAA is not authorized to receive PHI — this is the wall the protocol exists to enforce."
        },
        {
          "detail": "Evaluate the vendor's privacy and security posture, and request their standard business associate agreement for review.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review the proposed vendor's data handling and BAA terms"
        },
        {
          "detail": "Decide whether to sign the BAA and add the vendor to the approved list, or reject it.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "approve",
              "label": "Approve and sign BAA"
            },
            {
              "goto": "s10",
              "id": "reject",
              "label": "Reject the vendor"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Approve the new vendor?"
        },
        {
          "detail": "Record the vendor name, BAA execution date, and scope of approved use on the approved AI tool list.\n\nRecord: Approved AI tool list entry: vendor, BAA date, approved use scope",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Add the vendor to the approved AI tool list"
        },
        {
          "detail": "Tell the staff member the vendor was not approved and that PHI may not be used with that tool.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the requesting staff member of the rejection"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "AI tool approval — BAA, no-PHI-to-unlisted-tools wall and staff instruction — A staff member wants to paste a chart note into a public AI assistant, or a new AI vendor is proposed.",
      "title": "AI tool approval — BAA, no-PHI-to-unlisted-tools wall and staff instruction",
      "trigger": "A staff member wants to paste a chart note into a public AI assistant, or a new AI vendor is proposed",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California CMIA Civil Code §56.10",
          "source": "California CMIA Civil Code §56.10",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=56.10."
        },
        {
          "kind": "statute",
          "label": "California CCPA Civil Code §1798.100 et seq.",
          "source": "California CCPA Civil Code §1798.100 et seq.",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=1798.100."
        },
        {
          "kind": "regulation",
          "label": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "source": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.504"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "caai-009",
      "kind": "compliance",
      "materials": [
        "CMIA authorization form",
        "photo ID verification checklist",
        "accounting-of-disclosures log",
        "record request intake form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Record who is asking, what information they want, which patient it concerns, and how they contacted the practice (in person, phone, mail, portal). Do not pull or discuss any record contents yet.\n\nWhy: A written intake record is the first defensible proof of what was asked before anything was released.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the incoming request",
          "why": "A written intake record is the first defensible proof of what was asked before anything was released."
        },
        {
          "detail": "Compare the requestor and purpose against the CMIA/HIPAA treatment-payment-operations (TPO) categories.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "tpo",
              "label": "Yes — this is TPO (another treating provider, the patient's insurer for payment, or internal QA)"
            },
            {
              "goto": "s7",
              "id": "not-tpo",
              "label": "No — this is an employer, attorney, family member or other third party outside TPO"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a treatment, payment or healthcare-operations use?"
        },
        {
          "detail": "Process under the practice's standard TPO release procedure; a CMIA third-party authorization is not required for TPO uses.\n\nWhy: CMIA and HIPAA both carve out TPO from the authorization requirement — routing it here avoids delaying a legitimate care-coordination request.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Route as a routine TPO disclosure",
          "why": "CMIA and HIPAA both carve out TPO from the authorization requirement — routing it here avoids delaying a legitimate care-coordination request."
        },
        {
          "detail": "Enter the disclosure in the accounting-of-disclosures log immediately after release, before moving to the next task.\n\nWhy: Patients have a right to an accounting of who their information was disclosed to; an unlogged disclosure cannot be produced on request.\n\nRecord: Date, recipient, information disclosed, purpose, and authorization/order reference recorded in the accounting-of-disclosures log.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the disclosure",
          "why": "Patients have a right to an accounting of who their information was disclosed to; an unlogged disclosure cannot be produced on request."
        },
        {
          "detail": "For a non-TPO release, let the patient know the disclosure was made per their authorization, unless a legal order specifically restricts notice.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm completion with the patient where appropriate"
        },
        {
          "detail": "Disclosure request closed",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Disclosure request closed"
        },
        {
          "detail": "Confirm government-issued photo ID for an individual requestor; for an attorney or employer, confirm the entity and the name of the person calling matches any authorization on file.\n\nWhy: CMIA authorization protects the patient, not the requestor — releasing to an unverified party defeats the protection entirely.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify the requestor's identity and stated authority",
          "why": "CMIA authorization protects the patient, not the requestor — releasing to an unverified party defeats the protection entirely."
        },
        {
          "detail": "Check for a signed CMIA-compliant authorization already on file, or a subpoena/court order that independently compels release.",
          "forks": [
            {
              "advised": false,
              "goto": "s11",
              "id": "have-valid",
              "label": "Valid authorization or compelling legal order already on file"
            },
            {
              "advised": true,
              "goto": "s9",
              "id": "need-new",
              "label": "No valid authorization on file — one must be obtained from the patient first"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the requestor already hold a valid CMIA authorization or legal order?"
        },
        {
          "detail": "Name of the person/entity authorized to release; name of the person/entity authorized to receive; specific information to be disclosed; purpose of the disclosure; a signature and date; and an expiration date or event.\n\nWhy: A CMIA authorization missing any required element is not valid and cannot be relied on to release the record.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the authorization form carries every CMIA-required element",
          "why": "A CMIA authorization missing any required element is not valid and cannot be relied on to release the record."
        },
        {
          "detail": "Provide the form to the patient (or their legal representative), explain what will be released and to whom, and collect the signed original before proceeding.\n\nRecord: signed authorization form filed in the patient's record",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the authorization form to the patient and obtain a signed copy"
        },
        {
          "detail": "The compliance officer confirms the authorization (or legal order) is valid, current, and scoped to exactly the information being released, and signs off before front desk sends anything.\n\nWhy: A release outside the authorization's stated scope is a CMIA violation even when a signature exists.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before any information leaves the practice.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before any information leaves the practice",
          "why": "A release outside the authorization's stated scope is a CMIA violation even when a signature exists."
        },
        {
          "detail": "Redact or exclude any record content outside the authorization's stated scope before transmitting.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Prepare and send only the authorized scope of information"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "CMIA-compliant authorization for disclosures beyond treatment, payment and operations — An employer, attorney or family member requests a patient's information.",
      "title": "CMIA-compliant authorization for disclosures beyond treatment, payment and operations",
      "trigger": "An employer, attorney or family member requests a patient's information",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California CCPA Civil Code §1798.100 et seq. (as amended by CPRA)",
          "source": "California CCPA Civil Code §1798.100 et seq. (as amended by CPRA)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=1798.100."
        },
        {
          "kind": "statute",
          "label": "California CMIA Civil Code §56.10 (medical information carve-out from CCPA where CMIA applies)",
          "source": "California CMIA Civil Code §56.10 (medical information carve-out from CCPA where CMIA applies)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=56.10."
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "caai-010",
      "kind": "compliance",
      "materials": [
        "CCPA request intake form",
        "identity-verification checklist",
        "vendor/data-processor inventory",
        "request response log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record the request type (know, delete, correct, or opt-out of sale/sharing), the submitted contact information, and the date received.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Log the incoming request"
        },
        {
          "detail": "Confirm against the practice's current revenue, data-volume and data-sale thresholds whether CCPA obligations apply this year.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "applies",
              "label": "Threshold met — CCPA obligations apply"
            },
            {
              "goto": "s11",
              "id": "not-applies",
              "label": "Threshold not met this year"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the practice meet a CCPA applicability threshold?"
        },
        {
          "detail": "CCPA does not reach information already governed by CMIA/HIPAA — a request touching medical records routes to the CMIA disclosure protocol instead.",
          "forks": [
            {
              "goto": "s12",
              "id": "medical-scope",
              "label": "Request concerns medical/treatment records"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "web-scope",
              "label": "Request concerns non-medical website/marketing data only (forms filled out, cookies, analytics)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the request touch medical/treatment information rather than website data?"
        },
        {
          "detail": "Match the request against known contact information on file (email or phone used to submit a form) before acting on it.\n\nWhy: Fulfilling a deletion or know-request for the wrong person is itself a privacy failure.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Verify the requestor's identity to a reasonable degree of certainty",
          "why": "Fulfilling a deletion or know-request for the wrong person is itself a privacy failure."
        },
        {
          "detail": "Website form submissions, analytics/marketing tool exports, email list entries, and any third-party vendor or ad-tech processor listed in the vendor inventory.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify every system holding the requested data"
        },
        {
          "detail": "Confirm the request is verified, correctly scoped to non-medical data, and that deleting or disclosing the identified data will not remove records the practice is separately required to retain.\n\nWhy: A retention obligation (e.g. tax or contract records) can override a deletion request in part — this checkpoint catches that before data is destroyed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before deletion or disclosure is executed.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before deletion or disclosure is executed",
          "why": "A retention obligation (e.g. tax or contract records) can override a deletion request in part — this checkpoint catches that before data is destroyed."
        },
        {
          "detail": "Fulfill the know/delete/opt-out action in the website platform, marketing tool, and any third-party processor; request written deletion confirmation from each vendor that holds the data.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Execute the request across all identified systems"
        },
        {
          "detail": "Enter the completed request into the request response log the same day it is fulfilled.\n\nRecord: Request type, verification method, systems actioned, vendor confirmations received, and response date logged in the request response log.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the response"
        },
        {
          "detail": "Send written confirmation within the statutory response window describing what action was taken.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Notify the requestor of completion"
        },
        {
          "detail": "Consumer request closed",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Consumer request closed"
        },
        {
          "detail": "Reply that the practice is below CCPA applicability thresholds but will honor reasonable opt-out and deletion preferences where feasible, without conceding a legal obligation.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Send a courtesy response"
        },
        {
          "detail": "Hand the request to the office manager to process under the CMIA-compliant authorization protocol (caai-009) instead of the CCPA path.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Redirect to the CMIA/records-request process"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "CCPA consumer request (know, delete, opt-out) handling for non-medical website data where thresholds apply — A website visitor submits a privacy request through the site.",
      "title": "CCPA consumer request (know, delete, opt-out) handling for non-medical website data where thresholds apply",
      "trigger": "A website visitor submits a privacy request through the site",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California breach notice Civil Code §1798.82",
          "source": "California breach notice Civil Code §1798.82"
        },
        {
          "kind": "regulation",
          "label": "HIPAA breach notification rule 45 CFR 164.400-414",
          "source": "HIPAA breach notification rule 45 CFR 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-D"
        },
        {
          "kind": "regulation",
          "label": "California Office of the Attorney General — data breach reporting and sample notice guidance",
          "source": "California Office of the Attorney General — data breach reporting and sample notice guidance",
          "url": "https://oag.ca.gov/privacy/databreach/reporting"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "caai-011",
      "kind": "compliance",
      "materials": [
        "incident intake form",
        "breach risk-assessment worksheet",
        "California AG sample notice template",
        "affected-individual mailing list",
        "legal counsel contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Stop ongoing unauthorized access or disclosure immediately (revoke credentials, isolate the affected system) and notify the practice owner before any investigation or notice drafting begins.\n\nWhy: An active, uncontained breach keeps growing — containment always precedes documentation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Contain the exposure before anything else.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "it-vendor",
          "title": "Contain the exposure before anything else",
          "why": "An active, uncontained breach keeps growing — containment always precedes documentation."
        },
        {
          "detail": "Log the discovery date, what happened, what system or record was involved, and who reported it.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Open an incident record"
        },
        {
          "detail": "Assess all four 45 CFR 164.402/164.408 factors: (1) the nature and extent of the personal information involved, including likelihood of re-identification; (2) the unauthorized person who used the information or to whom it was disclosed; (3) whether the information was actually acquired or viewed, not merely accessible; and (4) the extent to which the risk has been mitigated. Then determine how many California residents are affected.\n\nWhy: Both the HIPAA breach rule and the California statute define 'breach' by unauthorized acquisition/use — a properly encrypted or unreadable dataset, or a low-probability-of-compromise result on all four factors, may fall outside the notice trigger.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Run the four-factor HIPAA risk assessment to determine whether a reportable breach occurred",
          "why": "Both the HIPAA breach rule and the California statute define 'breach' by unauthorized acquisition/use — a properly encrypted or unreadable dataset, or a low-probability-of-compromise result on all four factors, may fall outside the notice trigger."
        },
        {
          "detail": "California law adds an Attorney General notice requirement once more than 500 residents are affected by a single breach; the individual-notice duty applies regardless of count.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "over-500",
              "label": "More than 500 California residents affected"
            },
            {
              "goto": "s6",
              "id": "under-500",
              "label": "500 or fewer California residents affected"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "How many California residents are affected?"
        },
        {
          "detail": "Use the California AG's sample notice form as the base template, ready for counsel review; do not submit yet.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Prepare the Attorney General notification"
        },
        {
          "detail": "Name and contact information of the reporting entity; the categories of information believed compromised; the date or date range of the breach; a general description of the incident; the toll-free numbers of the major credit-reporting agencies where the breach includes SSN or driver's license data; and, where required, an offer of identity-theft protection.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the individual notice contains every required element"
        },
        {
          "detail": "Counsel reviews the completed draft Attorney General submission (where the over-500 threshold was met) and the completed draft individual notice content before either is sent — never before the drafts exist.\n\nWhy: The California statute prescribes specific required content for the notice — an unreviewed notice risks non-compliant wording that itself becomes a finding, and counsel cannot meaningfully review a draft that has not been written yet.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Legal review of the completed drafts before anything is sent.",
            "role": "legal counsel",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Legal review of the completed drafts before anything is sent",
          "why": "The California statute prescribes specific required content for the notice — an unreviewed notice risks non-compliant wording that itself becomes a finding, and counsel cannot meaningfully review a draft that has not been written yet."
        },
        {
          "detail": "Mail or otherwise deliver the individual notices without unreasonable delay, and no later than 60 days after discovery (45 CFR 164.404) — a hard outer deadline, not a target — consistent with the California statute's 'most expedient time possible' standard.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Send notices within the required timeframe"
        },
        {
          "detail": "Add the notice details to the incident record as soon as notices are sent, before starting corrective action.\n\nRecord: Notice date, recipient count, delivery method, and AG submission confirmation (if applicable) logged in the incident record.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record what was sent and to whom"
        },
        {
          "detail": "Close the vulnerability that allowed the breach (patch, credential rotation, access-control change) and document what was fixed.",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Complete and document corrective action"
        },
        {
          "detail": "Deliver the complete incident record — containment log, risk assessment, notices sent, AG confirmation, and corrective action — to the practice owner for final sign-off.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hand the closed incident file to the practice owner"
        },
        {
          "detail": "Breach incident closed",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Breach incident closed"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "California breach addendum — attorney general sample notice and content requirements — A HIPAA breach affects more than 500 California residents, or a non-PHI personal-information breach occurs.",
      "title": "California breach addendum — attorney general sample notice and content requirements",
      "trigger": "A HIPAA breach affects more than 500 California residents, or a non-PHI personal-information breach occurs",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "source": "California AB 3030, Health & Safety Code §1339.75 (GenAI patient-communication disclosure; provider-review exemption)",
          "url": "https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB3030"
        },
        {
          "kind": "statute",
          "label": "California CMIA Civil Code §56.10 (medical information handling by contracted vendors)",
          "source": "California CMIA Civil Code §56.10 (medical information handling by contracted vendors)"
        },
        {
          "kind": "regulation",
          "label": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "source": "HIPAA business associate requirements 45 CFR 164.502(e), 164.504(e)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.504"
        }
      ],
      "class": "ca-ai-disclosure-recording-consent",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "annual",
      "id": "caai-012",
      "kind": "compliance",
      "materials": [
        "AI acceptable-use policy document",
        "approved AI tool inventory",
        "staff attestation form",
        "training slide deck"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify whether this is the first-adoption case (a new AI tool is being brought into the practice) or the recurring annual attestation date.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "first-adoption",
              "label": "First AI tool being adopted — no policy exists yet"
            },
            {
              "goto": "s11",
              "id": "annual-cycle",
              "label": "Annual attestation date has arrived — policy already exists"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What triggered this cycle?"
        },
        {
          "detail": "Cover: which AI tools are approved for which purposes, the no-PHI-without-a-BAA vendor wall, the AB 3030 disclosure requirement for any patient-facing AI communication, the provider-review exemption and how it is logged, and consequences for policy violations.\n\nWhy: Without a written policy, individual staff make ad-hoc judgment calls about what is safe to paste into an AI tool — the vendor wall exists specifically to prevent that.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the AI acceptable-use policy",
          "why": "Without a written policy, individual staff make ad-hoc judgment calls about what is safe to paste into an AI tool — the vendor wall exists specifically to prevent that."
        },
        {
          "detail": "List every AI tool currently or about to be used in the practice, whether each has a signed business-associate agreement, and what category of data (PHI vs non-PHI) it is approved to touch.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the approved AI tool inventory"
        },
        {
          "detail": "Confirm the policy correctly states the vendor wall, the AB 3030 disclosure and provider-review exemption, and that the tool inventory matches what staff actually use before distributing it.\n\nWhy: An inaccurate policy — one that omits a tool staff already use, or misstates the disclosure exemption — trains staff on the wrong rule.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on the policy before it is issued.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on the policy before it is issued",
          "why": "An inaccurate policy — one that omits a tool staff already use, or misstates the disclosure exemption — trains staff on the wrong rule."
        },
        {
          "detail": "Send the current policy document and approved tool inventory to every staff member, including anyone who joined since the last cycle.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Distribute the policy to all staff"
        },
        {
          "detail": "Walk staff through the vendor wall in practice terms (what never gets pasted into an AI tool), where the AB 3030 disclosure applies, and how to report a suspected violation.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Deliver a short training session"
        },
        {
          "detail": "Every staff member reads the current policy and signs an attestation confirming they understand and will follow it.\n\nRecord: signed attestation form filed per staff member with the date",
          "id": "s7",
          "kind": "step",
          "role": "all-staff",
          "title": "Each staff member signs the attestation form"
        },
        {
          "detail": "Did every staff member complete the attestation?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "complete",
              "label": "All staff attested"
            },
            {
              "goto": "s12",
              "id": "incomplete",
              "label": "One or more staff members have not yet attested"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did every staff member complete the attestation?"
        },
        {
          "detail": "Close out the cycle by entering the full record into the compliance calendar and scheduling next year's date.\n\nRecord: Policy version, distribution date, training date, and full attestation roster logged with the next annual due date scheduled.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log completion of the attestation cycle"
        },
        {
          "detail": "Policy issued and attestation cycle closed",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Policy issued and attestation cycle closed"
        },
        {
          "detail": "Check whether any new AI tool was adopted informally since the last cycle, and whether any regulatory citation in the policy needs a currency check.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review the existing policy for needed updates"
        },
        {
          "detail": "Identify who has not attested and set a firm completion deadline before the record is closed out.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Follow up with outstanding staff"
        }
      ],
      "subclass": "california-ai-disclosure-and-recording-consent",
      "summary": "Practice AI acceptable-use policy issue and annual staff attestation — The practice adopts its first AI tool, or the annual policy attestation date arrives.",
      "title": "Practice AI acceptable-use policy issue and annual staff attestation",
      "trigger": "The practice adopts its first AI tool, or the annual policy attestation date arrives",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        },
        {
          "kind": "regulation",
          "label": "FDA aligner device class II labeling",
          "source": "FDA aligner device class II labeling",
          "url": "https://www.fda.gov/"
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "calo-001",
      "kind": "clinical",
      "materials": [
        "intraoral exam findings",
        "case-selection checklist (crowding/spacing range, bite classification, periodontal status)",
        "specialist referral list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist asks what the patient wants improved (crowding, spacing, bite, appearance) and notes any prior orthodontic history.\n\nWhy: Case selection starts from what the patient is actually trying to achieve, not just what is visible on exam.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Gather the patient's chief concern and goals",
          "why": "Case selection starts from what the patient is actually trying to achieve, not just what is visible on exam."
        },
        {
          "detail": "Dentist checks: degree of crowding/spacing (mild-to-moderate range suitable for GP-delivered aligners), bite classification (Class I vs skeletal discrepancy), periodontal health, absence of active decay, root and bone levels on radiographs.\n\nWhy: GP-delivered clear aligners are indicated for mild-to-moderate cases within the dentist's training; skeletal or severe cases carry different risk.\n\nRecord: screening checklist results in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Run the clinical screening checklist",
          "why": "GP-delivered clear aligners are indicated for mild-to-moderate cases within the dentist's training; skeletal or severe cases carry different risk."
        },
        {
          "detail": "Dentist weighs checklist findings, complexity, and their own training/comfort level against the case.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "treat-gp",
              "label": "Case is within mild-to-moderate range and GP training — proceed with records"
            },
            {
              "goto": "s8",
              "id": "refer-out",
              "label": "Skeletal discrepancy, severe crowding, or beyond GP scope — refer to a specialist"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide treat-in-house versus refer to a specialist"
        },
        {
          "detail": "Dentist explains clear-aligner versus fixed-appliance options, expected treatment length, and a general cost range, and answers questions.\n\nWhy: Informed case acceptance reduces mid-treatment dropout.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss treatment options, timeline, and cost range with the patient",
          "why": "Informed case acceptance reduces mid-treatment dropout."
        },
        {
          "detail": "Patient (or caregiver for a minor) signs consent to begin the orthodontic records and treatment-planning process before any records are taken.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Patient consent before proceeding to records.",
            "type": "safety"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Patient consent before proceeding to records"
        },
        {
          "detail": "Record the screening findings, treat-or-refer decision, and rationale in the patient chart.\n\nRecord: case-selection decision and rationale in the chart",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Log the case-selection decision"
        },
        {
          "detail": "Screening and case-selection complete",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Screening and case-selection complete"
        },
        {
          "detail": "Front desk provides the patient a specialist referral with the screening summary and reason for referral.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to specialist referral"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Orthodontic screening and GP case-selection criteria (treat versus refer) — A patient asks about straightening teeth, or crowding is noted at exam.",
      "title": "Orthodontic screening and GP case-selection criteria (treat versus refer)",
      "trigger": "A patient asks about straightening teeth, or crowding is noted at exam",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "calo-002",
      "kind": "clinical",
      "materials": [
        "digital scanner or impression material",
        "standardized photo series checklist (intraoral, extraoral, smile)",
        "panoramic/cephalometric radiograph equipment as indicated",
        "records submission form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Assistant checks the chart for a current radiograph series and recent photos that may not need to be retaken.\n\nWhy: Avoids unnecessary radiation exposure and duplicate imaging.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm which records are already on file",
          "why": "Avoids unnecessary radiation exposure and duplicate imaging."
        },
        {
          "detail": "Assistant or dentist captures a full-arch digital intraoral scan (or conventional impressions if no scanner is available), including bite registration.\n\nWhy: The scan is the base data set the treatment plan is built from.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Capture a full-arch digital scan or take impressions",
          "why": "The scan is the base data set the treatment plan is built from."
        },
        {
          "detail": "Take the full standardized series: frontal repose, frontal smile, right and left buccal, upper and lower occlusal, and profile — per the office's standardized photo series checklist.\n\nWhy: A consistent photo series lets the treating dentist and any reviewer compare pre-treatment to progress accurately.\n\nRecord: photo series filed in the patient's imaging record",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Capture the standardized photo series",
          "why": "A consistent photo series lets the treating dentist and any reviewer compare pre-treatment to progress accurately."
        },
        {
          "detail": "Dentist decides whether a current panoramic and/or cephalometric radiograph is needed based on what is on file and clinical findings.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "current-on-file",
              "label": "Current radiographs already on file — no new exposure needed"
            },
            {
              "goto": "s9",
              "id": "new-radiograph",
              "label": "New panoramic or cephalometric radiograph indicated"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Determine whether new radiographs are indicated"
        },
        {
          "detail": "Assistant assembles the scan/impressions, photo series, and radiographs into the records submission form for the treatment-plan review step.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Compile and submit the records package"
        },
        {
          "detail": "Dentist checks the scan for full arch coverage and accurate bite registration, and confirms photos are in focus and correctly labeled.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pass",
              "label": "Records complete and usable"
            },
            {
              "goto": "s2",
              "id": "retake",
              "label": "One or more records need a retake"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Dentist reviews record quality before submission"
        },
        {
          "detail": "Record which records were captured, the date, and that the package was submitted for treatment-plan review.\n\nRecord: records package contents and submission date in the chart",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Log records submission"
        },
        {
          "detail": "Records captured and submitted",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Records captured and submitted"
        },
        {
          "detail": "Assistant takes the panoramic and/or cephalometric radiograph per the office's radiation safety protocol.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Take the indicated radiograph"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Aligner records — scans, standardized photos, panoramic or cephalometric as indicated — The case is accepted and records must be submitted.",
      "title": "Aligner records — scans, standardized photos, panoramic or cephalometric as indicated",
      "trigger": "The case is accepted and records must be submitted",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "calo-003",
      "kind": "clinical",
      "materials": [
        "digital setup viewer software",
        "proposed movement plan and IPR map",
        "attachment placement diagram",
        "root/bone limit reference (radiographs)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist opens the returned digital setup in the viewer software and confirms it matches the submitted records.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Receive the proposed digital setup"
        },
        {
          "detail": "Dentist steps through the movement animation, checking that the sequence and final position match the treatment goals discussed with the patient.\n\nWhy: The proposed setup is a starting point, not an approved plan — movements outside what was discussed need to be caught before the case proceeds.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Review the proposed tooth movements stage by stage",
          "why": "The proposed setup is a starting point, not an approved plan — movements outside what was discussed need to be caught before the case proceeds."
        },
        {
          "detail": "Dentist checks each proposed IPR location and amount against what is clinically appropriate for the contact and enamel thickness involved.\n\nWhy: Over-aggressive or misplaced IPR can compromise enamel and periodontal contacts.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review the interproximal reduction (IPR) map",
          "why": "Over-aggressive or misplaced IPR can compromise enamel and periodontal contacts."
        },
        {
          "detail": "Dentist checks that proposed attachment shapes and locations support the planned movements without interfering with the bite or aesthetics in visible areas.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Review attachment placement"
        },
        {
          "detail": "Dentist cross-references the proposed movements against the patient's radiographs to confirm no movement pushes a root beyond the available bone.\n\nWhy: Root movement beyond the bony envelope risks dehiscence or resorption.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Check proposed movements against root and bone limits",
          "why": "Root movement beyond the bony envelope risks dehiscence or resorption."
        },
        {
          "detail": "The treating dentist gives explicit written approval of the final digital setup — or requests specific revisions — before any aligner series is manufactured.\n\nWhy: Once aligners are manufactured, changes require a new setup and delay; approval must be a deliberate clinical decision, not a default.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before the plan is finalized and aligners are ordered.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before the plan is finalized and aligners are ordered",
          "why": "Once aligners are manufactured, changes require a new setup and delay; approval must be a deliberate clinical decision, not a default."
        },
        {
          "detail": "Based on the review, decide whether to approve the setup as proposed or send back specific revision requests.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "approve",
              "label": "Setup meets clinical goals and limits — approve"
            },
            {
              "goto": "s11",
              "id": "revise",
              "label": "Revisions needed — send back specific change requests"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Approve or request revisions"
        },
        {
          "detail": "Dentist confirms the approved setup and places the order for the full aligner series to be manufactured.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Order the aligner series"
        },
        {
          "detail": "Record the approved setup version, date of approval, and treating dentist's sign-off in the chart.\n\nRecord: approved treatment-plan version and sign-off in the chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log plan approval"
        },
        {
          "detail": "Treatment plan approved and aligners ordered",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Treatment plan approved and aligners ordered"
        },
        {
          "detail": "Dentist documents the specific movements, IPR, or attachment changes requested and resubmits for a revised setup.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Submit revision requests"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Digital treatment-plan review — movements, IPR, attachments, root and bone limits, approval — The manufacturer or lab returns a proposed digital setup.",
      "title": "Digital treatment-plan review — movements, IPR, attachments, root and bone limits, approval",
      "trigger": "The manufacturer or lab returns a proposed digital setup",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-patient",
      "id": "calo-004",
      "kind": "clinical",
      "materials": [
        "approved aligner series",
        "attachment bonding template and composite",
        "IPR strips/discs",
        "wear-instruction handout",
        "aligner case"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "patient",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist seats aligner #1 and checks it fully seats on all teeth without excessive rocking or gapping.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Try in the first aligner and verify fit"
        },
        {
          "detail": "Patient (or caregiver for a minor) confirms they have reviewed the approved treatment plan, cost, and risks — including permanent interproximal enamel reduction — and consents before IPR or attachment bonding begins.\n\nWhy: IPR is permanent and attachment bonding alters enamel; the patient's consent to be worked up is not the same as consent to the specific finalized plan now being executed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Patient consent to the approved plan before any irreversible step.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Patient consent to the approved plan before any irreversible step",
          "why": "IPR is permanent and attachment bonding alters enamel; the patient's consent to be worked up is not the same as consent to the specific finalized plan now being executed."
        },
        {
          "detail": "Dentist performs interproximal reduction at the locations and amounts specified in the approved digital plan, matching the plan exactly.\n\nWhy: Deviating from the approved IPR map changes the space available for the planned movements.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Execute any IPR planned for the early stages",
          "why": "Deviating from the approved IPR map changes the space available for the planned movements."
        },
        {
          "detail": "Assistant preps enamel and dentist bonds each attachment using the delivery template at the locations shown in the approved digital setup.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Bond attachments per the approved placement diagram"
        },
        {
          "detail": "Dentist seats aligner #1 over the new attachments and checks occlusal contacts and comfort.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the first aligner and check occlusion"
        },
        {
          "detail": "Explain minimum daily wear hours, removal only for eating/drinking/brushing, cleaning the aligner, and the schedule for switching to the next aligner in the series.\n\nWhy: Compliance with wear time is the single biggest determinant of whether the plan tracks as designed.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Give wear and care instructions",
          "why": "Compliance with wear time is the single biggest determinant of whether the plan tracks as designed."
        },
        {
          "detail": "Dentist or assistant asks the patient to repeat back the wear-hours requirement and switch schedule.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "confirmed",
              "label": "Patient repeats instructions correctly"
            },
            {
              "goto": "s6",
              "id": "unclear",
              "label": "Patient is unclear — re-explain with the handout"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "assistant",
          "title": "Confirm the patient understands the wear schedule"
        },
        {
          "detail": "Front desk schedules the patient's first progress check appointment at the interval set by the treating dentist (typically 6-10 weeks).",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the first progress check"
        },
        {
          "detail": "Record which aligner number was delivered, IPR performed, attachments bonded, and confirmation that wear instructions were given and understood.\n\nRecord: delivery details, IPR and attachment log, wear-instruction confirmation in the chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log the delivery visit"
        },
        {
          "detail": "First aligner delivered",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "First aligner delivered"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "First-aligner delivery — attachment bonding, IPR execution, wear instructions — Aligners have arrived and the patient is seated for the start.",
      "title": "First-aligner delivery — attachment bonding, IPR execution, wear instructions",
      "trigger": "Aligners have arrived and the patient is seated for the start",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "calo-005",
      "kind": "clinical",
      "materials": [
        "current aligner and approved digital plan for comparison",
        "tracking assessment checklist",
        "wear-time compliance log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Dentist or assistant asks the patient about daily wear hours and any missed days since the last visit.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Review wear-time compliance since the last check"
        },
        {
          "detail": "Inspect each bonded attachment for wear, chipping, or debonding; note any that need to be repaired at this or a future visit.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Check attachment integrity"
        },
        {
          "detail": "Dentist checks the current aligner's fit against the digital plan — full seating with minimal gapping at the incisal or gingival edge indicates on-track movement.\n\nWhy: Tracking assessment at each check is what catches a drifting case early, before several stages compound the error.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "on-track",
              "label": "Aligner fits fully — case is tracking as planned"
            },
            {
              "goto": "s8",
              "id": "off-track",
              "label": "Gaps or lag noted — not tracking (see calo-006)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess whether the current aligner is tracking as planned",
          "why": "Tracking assessment at each check is what catches a drifting case early, before several stages compound the error."
        },
        {
          "detail": "Dentist confirms how many aligner stages the patient can wear before the next check and re-confirms the switch interval.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Advance the patient to the next set of stages and confirm wear schedule"
        },
        {
          "detail": "Front desk books the next 6-10 week check-in, or the final check before refinement/retention if the series is nearly complete.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the next progress check"
        },
        {
          "detail": "Record wear-time compliance, attachment status, tracking assessment, and next-check date in the chart.\n\nRecord: compliance, attachment status and tracking assessment in the chart",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Log the progress check findings"
        },
        {
          "detail": "Progress check complete",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Progress check complete"
        },
        {
          "detail": "Dentist starts the aligner-not-tracking recovery protocol (calo-006) rather than simply advancing the patient to the next stage.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the not-tracking recovery protocol"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Progress check — tracking, compliance, attachment integrity, next-stage handoff — A scheduled 6-10 week check-in during active treatment.",
      "title": "Progress check — tracking, compliance, attachment integrity, next-stage handoff",
      "trigger": "A scheduled 6-10 week check-in during active treatment",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "calo-006",
      "kind": "clinical",
      "materials": [
        "aligner seating aids (a soft foam or silicone tray-seater the patient bites down on)",
        "wear-time compliance log",
        "digital scanner for a new scan if refinement is needed"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist asks about wear-time compliance, checks attachment integrity, and examines whether the gap is isolated to one tooth or general across the arch.\n\nWhy: The fix differs depending on whether the cause is a compliance gap versus a movement the aligner series simply cannot achieve.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the likely cause of the tracking gap",
          "why": "The fix differs depending on whether the cause is a compliance gap versus a movement the aligner series simply cannot achieve."
        },
        {
          "detail": "Based on the cause and size of the gap, choose the least disruptive fix that is still likely to work.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "seating-aids",
              "label": "Minor gap, likely compliance — recommend aligner seating aids and re-wear the current stage"
            },
            {
              "goto": "s8",
              "id": "backtrack",
              "label": "Moderate gap — backtrack a few stages and re-advance more slowly"
            },
            {
              "goto": "s9",
              "id": "rescan",
              "label": "Persistent or large gap — new scan and refinement order needed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide on a recovery approach"
        },
        {
          "detail": "Dentist instructs the patient to use aligner seating aids to fully seat the tray and to continue wearing the current stage for an extra period before advancing.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Recommend aligner seating aids and re-wear the current stage"
        },
        {
          "detail": "Schedule a recheck in 2-3 weeks to confirm the seating-aid or backtrack approach restored tracking before advancing further.\n\nWhy: Advancing again without confirming the fix worked risks compounding the same tracking problem.",
          "id": "s4",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1512000,
          "title": "Wait and recheck tracking at the next visit",
          "why": "Advancing again without confirming the fix worked risks compounding the same tracking problem."
        },
        {
          "detail": "Dentist reassesses fit at the recheck visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "restored",
              "label": "Tracking restored — resume normal progress checks"
            },
            {
              "goto": "s9",
              "id": "still-off",
              "label": "Still not tracking — escalate to a new scan and refinement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm whether tracking is restored at the recheck"
        },
        {
          "detail": "Record the cause identified, the recovery approach used, and the outcome in the chart.\n\nRecord: tracking issue, recovery approach and outcome in the chart",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Log the tracking issue and resolution"
        },
        {
          "detail": "Tracking issue resolved or escalated to refinement",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Tracking issue resolved or escalated to refinement"
        },
        {
          "detail": "Dentist has the patient return to wearing an earlier aligner in the series that still fits fully, then re-advance more slowly with a longer wear period per stage.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Backtrack to an earlier, fully-tracking stage"
        },
        {
          "detail": "Assistant captures a new full-arch scan of the current tooth positions to send for a refinement setup (see calo-007).",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Take a new scan for a refinement plan"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Aligner not tracking — seating aids, backtrack, or new scan and refinement decision — Gaps between aligner and teeth or lag noticed at a check.",
      "title": "Aligner not tracking — seating aids, backtrack, or new scan and refinement decision",
      "trigger": "Gaps between aligner and teeth or lag noticed at a check",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "calo-007",
      "kind": "clinical",
      "materials": [
        "digital scanner",
        "original treatment goals from the chart",
        "refinement setup viewer"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Dentist compares the current result against the original treatment goals discussed at case acceptance, noting specifically what is left to correct.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Assess which treatment goals remain unmet"
        },
        {
          "detail": "Dentist explains that a refinement scan and an additional round of aligners are needed to finish the remaining movement, and confirms the patient's continued consent.\n\nWhy: Refinement is a normal part of many aligner cases, but patients should not be surprised by an additional round.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the need for refinement to the patient",
          "why": "Refinement is a normal part of many aligner cases, but patients should not be surprised by an additional round."
        },
        {
          "detail": "Patient confirms understanding and consents to proceed with a refinement scan and additional aligner series before it is ordered.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Patient consent before ordering additional aligners.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Patient consent before ordering additional aligners"
        },
        {
          "detail": "Assistant captures a new full-arch scan of the current tooth positions to send for the refinement setup.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Capture the refinement scan"
        },
        {
          "detail": "Dentist reviews the returned refinement movement plan against the still-unmet goals, checking movements, any new IPR, and attachment changes.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Review the proposed refinement setup"
        },
        {
          "detail": "Treating dentist gives explicit approval of the refinement setup before the additional aligner series is manufactured.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before the refinement order is placed.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before the refinement order is placed"
        },
        {
          "detail": "Dentist confirms the approved refinement setup and places the order for the additional aligners.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Order the refinement aligner series"
        },
        {
          "detail": "Front desk books the visit to deliver the first refinement aligner once the series arrives.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the refinement delivery appointment"
        },
        {
          "detail": "Record which goals remained unmet, the refinement plan approved, and the order date in the chart.\n\nRecord: refinement rationale, approved plan and order date in the chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log the refinement decision and order"
        },
        {
          "detail": "Refinement ordered",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Refinement ordered"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Refinement scan and additional-aligner order — The active series is complete but goals are not met.",
      "title": "Refinement scan and additional-aligner order",
      "trigger": "The active series is complete but goals are not met",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        },
        {
          "kind": "generic",
          "label": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention) — generic functional equivalent; no independently published standard exists under this name"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source record itself carries a null URL and states, verbatim, 'Generic functional equivalent of vendor aligner platform workflows (never reproduced).' Searched for an independent published standard covering aligner-therapy screening, records, digital-plan review, delivery, tracking, refinement, and retention under any professional-association name; none was found — vendor platform workflows (e.g., Invisalign ClinCheck) are proprietary and not reproduced here, and no AAO/ADA position statement was located that governs this exact operational sequence end-to-end.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent of vendor aligner platform workflows (never reproduced)",
              "url": null
            }
          },
          "source": "In-house clear-aligner clinical workflow procedure (screening, records, digital plan review, delivery, progress checks, refinement, retention); no independently published standard exists under this name — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "calo-008",
      "kind": "clinical",
      "materials": [
        "final scan for retainer fabrication",
        "retainer options (removable clear vs bonded)",
        "retention wear-schedule handout"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison",
        "patient",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Dentist compares the final result to the original treatment goals and confirms active movement is complete.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm treatment goals are met"
        },
        {
          "detail": "Dentist explains removable clear retainer versus a bonded retainer option, including care and longevity trade-offs.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss retainer options with the patient"
        },
        {
          "detail": "Patient selects the retainer type based on the discussion.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "removable",
              "label": "Removable clear retainer"
            },
            {
              "goto": "s4",
              "id": "bonded",
              "label": "Bonded retainer (upper and/or lower)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "patient",
          "title": "Patient chooses retainer type"
        },
        {
          "detail": "Assistant captures a full-arch scan of the final tooth positions to send to the lab for retainer fabrication.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Capture the final scan for retainer fabrication"
        },
        {
          "detail": "Lab liaison submits the final scan and retainer type to the lab and tracks expected turnaround.",
          "id": "s5",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send the retainer order to the lab"
        },
        {
          "detail": "Dentist seats and adjusts the retainer for fit, then explains the wear schedule (typically full-time initially, tapering to nights only) using the retention wear-schedule handout.\n\nWhy: Relapse after active treatment is common without a clear, followed wear schedule.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Deliver the retainer and give wear instructions",
          "why": "Relapse after active treatment is common without a clear, followed wear schedule."
        },
        {
          "detail": "Front desk books follow-up retainer checks per the office's schedule (commonly at a few weeks, 6 months, and 12 months).",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule retainer checks"
        },
        {
          "detail": "Track time to the early retainer check appointment, typically 2-4 weeks after delivery, the window where fit problems and early relapse are most correctable.",
          "id": "s8",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1814400,
          "title": "Wait until the early retainer check"
        },
        {
          "detail": "Dentist checks the retainer still seats fully and asks about wear-schedule compliance and any early fit problems since delivery.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "fits-well",
              "label": "Retainer fits well and patient is wearing it as instructed"
            },
            {
              "goto": "s4",
              "id": "early-issue",
              "label": "Fit problem or early relapse noted — reassess and consider a new retainer"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess retainer fit shortly after delivery"
        },
        {
          "detail": "Track time to the next retainer check appointment (approximately 6 months as a default interval).",
          "id": "s10",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 15552000,
          "title": "Wait until the 6-month retainer check"
        },
        {
          "detail": "Dentist checks the retainer still seats fully and screens for any shift in tooth position since delivery.",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "stable",
              "label": "Retainer fits and position is stable — continue to the 12-month check"
            },
            {
              "goto": "s4",
              "id": "relapse",
              "label": "Relapse or retainer damage noted — reassess and consider a new retainer"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess retainer fit and any relapse at the 6-month check"
        },
        {
          "detail": "Track time to the 12-month retainer check appointment (approximately a further 6 months after the 6-month check).",
          "id": "s12",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 15768000,
          "title": "Wait until the 12-month retainer check"
        },
        {
          "detail": "Dentist checks the retainer still seats fully and screens for any shift in tooth position since the 6-month check.",
          "forks": [
            {
              "advised": true,
              "goto": "s14",
              "id": "stable-12",
              "label": "Retainer fits and position is stable at 12 months — continue routine wear"
            },
            {
              "goto": "s4",
              "id": "relapse-12",
              "label": "Relapse or retainer damage noted — reassess and consider a new retainer"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess retainer fit and stability at the 12-month check"
        },
        {
          "detail": "Record retainer type delivered, wear schedule given, and findings at each retainer check in the chart.\n\nRecord: retainer type, wear schedule and check findings in the chart",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Log the retention status"
        },
        {
          "detail": "Retention protocol in place",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Retention protocol in place"
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Retention — retainer type, delivery, wear schedule and retainer checks — Treatment goals are achieved and active movement ends.",
      "title": "Retention — retainer type, delivery, wear schedule and retainer checks",
      "trigger": "Treatment goals are achieved and active movement ends",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        },
        {
          "kind": "regulation",
          "label": "FDA aligner device class II labeling",
          "source": "FDA aligner device class II labeling",
          "url": "https://www.fda.gov/"
        },
        {
          "kind": "generic",
          "label": "Phone intake script and stage-tracking decision logic: vendor aligner platform workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Phone intake script and stage-tracking decision logic: generic functional equivalent of vendor aligner platform workflows (never reproduced)"
          },
          "source": "Phone intake script and stage-tracking decision logic: vendor aligner platform workflows — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "calo-009",
      "kind": "clinical",
      "materials": [
        "current stage tray inventory (kept spares if issued)",
        "prior and next stage aligner sets",
        "scan/impression kit for a rescan if needed",
        "retainer case fee schedule"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Front desk asks which appliance (active aligner or retainer), which stage number, how long ago it went missing or broke, and whether the patient still has the previous stage.\n\nWhy: The stage number and whether a prior tray survives determine every downstream option.\n\nRecord: patient name, appliance type, stage number, date lost/broken, prior stage availability",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Front desk takes the call and records what is missing",
          "why": "The stage number and whether a prior tray survives determine every downstream option."
        },
        {
          "detail": "Front desk routes based on whether the patient is still in active movement or already in the retention phase.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "active",
              "label": "Active aligner (mid-treatment)"
            },
            {
              "goto": "s8",
              "id": "retainer",
              "label": "Retainer (post-treatment)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this an active treatment aligner or a finished-case retainer?"
        },
        {
          "detail": "Dentist or front desk (per office policy) checks how many days have passed since the aligner was lost against the practice's own threshold for tooth-position drift.\n\nWhy: Teeth can begin relapsing toward their prior position within days of an aligner being out; the threshold decides whether the current stage still fits.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "short-gap",
              "label": "Within the practice's short-gap threshold"
            },
            {
              "goto": "s11",
              "id": "long-gap",
              "label": "Beyond the threshold"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "How long has the aligner been out of the mouth?",
          "why": "Teeth can begin relapsing toward their prior position within days of an aligner being out; the threshold decides whether the current stage still fits."
        },
        {
          "detail": "If the patient kept the previous stage tray, instruct them to wear it full-time until a replacement current-stage tray is fitted; if no prior stage is available and the next stage was already fabricated, have them try the next stage instead per dentist direction.\n\nWhy: Continuing wear on some tray, even an adjacent stage, limits how far teeth can drift before the next scheduled check.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Instruct the patient to wear the prior stage (if kept) or move to the next stage early",
          "why": "Continuing wear on some tray, even an adjacent stage, limits how far teeth can drift before the next scheduled check."
        },
        {
          "detail": "Office places the replacement order for the current stage (and next stage if advancing early emptied the spare), noting any patient-responsibility fee per the practice's policy.\n\nWhy: The patient needs a physical tray back in the mouth as soon as possible to hold the position reached.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Order the replacement aligner set for the affected stage(s)",
          "why": "The patient needs a physical tray back in the mouth as soon as possible to hold the position reached."
        },
        {
          "detail": "Record the appliance type, stage, cause if known (chewed by pet, thrown away with a napkin, etc.), gap duration, resolution chosen, and any fee charged.\n\nRecord: appliance type, stage, gap duration, resolution, fee status",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the lost/broken appliance event and resolution"
        },
        {
          "detail": "Lost/broken appliance event closed",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Lost/broken appliance event closed"
        },
        {
          "detail": "Dentist checks how far post-treatment the patient is and how long the retainer has been out; recent finishers and longer gaps carry higher relapse risk than patients years into stable retention.\n\nWhy: Relapse risk after active treatment ends is highest in the first months and remains real for years, so a lost retainer is not routine even though severity is low.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Assess retention risk for the lost retainer",
          "why": "Relapse risk after active treatment ends is highest in the first months and remains real for years, so a lost retainer is not routine even though severity is low."
        },
        {
          "detail": "If the patient has an older prior retainer, instruct them to wear it in the interim; otherwise advise limiting risk factors (avoid skipped nights) until the new retainer is ready, per dentist judgment.\n\nWhy: Some retention pressure is better than none while a replacement is made.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Give interim instructions while a new retainer is fabricated",
          "why": "Some retention pressure is better than none while a replacement is made."
        },
        {
          "detail": "Assistant or dentist captures a new impression/scan of the current position and sends it to the lab liaison for retainer fabrication, per the retention protocol's materials list.\n\nWhy: A replacement retainer must be made from the patient's current tooth positions, not the original finished-case model.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Take a new impression or scan and send for retainer fabrication",
          "why": "A replacement retainer must be made from the patient's current tooth positions, not the original finished-case model."
        },
        {
          "detail": "Front desk books the patient for a rescan appointment; dentist will evaluate whether the case can resume from a mid-series stage or needs a refinement scan per the refinement protocol.\n\nWhy: A gap long enough to allow relapse means the digital plan no longer matches the mouth, so continuing the old series risks aligners that don't seat.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a visit for a fresh scan and revised plan",
          "why": "A gap long enough to allow relapse means the digital plan no longer matches the mouth, so continuing the old series risks aligners that don't seat."
        },
        {
          "detail": "At the rescan visit, dentist checks current tooth positions against the last well-tracking stage, decides whether to resume the existing series or trigger a refinement scan, and documents the decision.\n\nWhy: Resuming too far into the series when teeth have relapsed risks the next trays not seating; resuming too conservatively wastes trays that would have fit.\n\nRecord: resume stage decided and rationale",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist evaluates fit and decides resume point",
          "why": "Resuming too far into the series when teeth have relapsed risks the next trays not seating; resuming too conservatively wastes trays that would have fit."
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Lost or broken aligner or retainer — same-stage, next-stage or replacement decision — A patient calls that an aligner or retainer is lost or cracked.",
      "title": "Lost or broken aligner or retainer — same-stage, next-stage or replacement decision",
      "trigger": "A patient calls that an aligner or retainer is lost or cracked",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        },
        {
          "kind": "regulation",
          "label": "FDA aligner device class II labeling",
          "source": "FDA aligner device class II labeling",
          "url": "https://www.fda.gov/"
        },
        {
          "kind": "generic",
          "label": "Chairside relief technique and referral-communication script — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Chairside relief technique and referral-communication script: generic functional equivalent"
          },
          "source": "Chairside relief technique and referral-communication script — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "calo-010",
      "kind": "clinical",
      "materials": [
        "orthodontic wire cutters/distal end cutter",
        "orthodontic wax",
        "cotton pliers",
        "topical relief material",
        "sterile gauze"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ask whether the patient is in active pain from a poking wire, loose bracket, or loose band, whether they know who their treating orthodontist is, and offer the next same-day opening.\n\nWhy: A poking wire causing soft-tissue irritation is uncomfortable but rarely urgent — same-day chairside relief, not an emergency-room referral, is the right response.\n\nRecord: patient name, complaint, treating office if known",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Front desk or assistant takes the call and offers same-day relief",
          "why": "A poking wire causing soft-tissue irritation is uncomfortable but rarely urgent — same-day chairside relief, not an emergency-room referral, is the right response."
        },
        {
          "detail": "Dentist checks whether the patient is under this practice's own active treatment plan or is presenting from an outside orthodontic office.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "outside",
              "label": "Outside patient in fixed braces from another office"
            },
            {
              "goto": "s3",
              "id": "own-aligner",
              "label": "This practice's own aligner patient with an attachment or IPR issue"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this the practice's own aligner or GP-ortho patient, or an outside patient in braces?"
        },
        {
          "detail": "Dentist explains the planned trim, reseat, or removal to the patient and obtains verbal agreement before touching another office's appliance; dentist or assistant then identifies the offending wire end or loose component; typically cuts a protruding distal wire end short and blunts it, tucks it, or covers it with orthodontic wax; re-seats a loose band if it can be safely reseated, or removes a fully detached bracket if it is loose enough to be a choking or laceration risk.\n\nWhy: The goal is comfort and safety, not to alter the treatment plan designed by the patient's treating orthodontist.\n\nRecord: which component was adjusted, wax dispensed y/n, bracket removed y/n",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Provide chairside relief for the poking wire, bracket or band",
          "why": "The goal is comfort and safety, not to alter the treatment plan designed by the patient's treating orthodontist."
        },
        {
          "detail": "Dentist or assistant accounts for a fully detached bracket, band, or wire segment removed during relief, confirming it was retrieved and is not unaccounted for in the patient's mouth or airway.\n\nWhy: A removed component was flagged as a choking or laceration risk; the relief is not complete until it is confirmed recovered, not merely removed.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "recovered",
              "label": "Component recovered or none was removed"
            },
            {
              "goto": "s9",
              "id": "unaccounted",
              "label": "Component not accounted for — treat as a possible swallowed/aspirated object"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm any removed or displaced component was recovered",
          "why": "A removed component was flagged as a choking or laceration risk; the relief is not complete until it is confirmed recovered, not merely removed."
        },
        {
          "detail": "Dentist determines whether the relief provided (trim, wax, reseat) is purely comfort-level, or whether a component had to be removed (e.g. a detached bracket) that the treating office will need to replace to keep the plan on track.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "comfort-only",
              "label": "Comfort-only adjustment, plan unaffected"
            },
            {
              "goto": "s10",
              "id": "component-removed",
              "label": "A bracket or band had to be removed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does anything done today change the treating orthodontist's plan?"
        },
        {
          "detail": "Give the patient a supply of orthodontic wax and instructions on applying it to any future poking spots, and advise contacting their treating orthodontist for their next regular adjustment.\n\nWhy: Wax lets the patient manage minor recurrences themselves until their own orthodontist's next visit.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Send the patient home with orthodontic wax and self-care instructions",
          "why": "Wax lets the patient manage minor recurrences themselves until their own orthodontist's next visit."
        },
        {
          "detail": "Record the complaint, relief provided, whether the treating office was notified, and any fee charged or waived as a courtesy.\n\nRecord: complaint, relief given, treating-office notification status, fee status",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the courtesy visit in the chart"
        },
        {
          "detail": "Orthodontic courtesy-relief visit closed",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Orthodontic courtesy-relief visit closed"
        },
        {
          "detail": "Dentist stops the visit, assesses the patient for choking or respiratory distress, and follows the office's swallowed/aspirated-foreign-object protocol, including calling 911 if the patient shows any airway or breathing compromise.\n\nWhy: A small metal component that cannot be accounted for may have been swallowed or aspirated; airway safety takes priority over completing the relief visit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate a possible swallowed or aspirated component.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Escalate a possible swallowed or aspirated component",
          "why": "A small metal component that cannot be accounted for may have been swallowed or aspirated; airway safety takes priority over completing the relief visit."
        },
        {
          "detail": "With the patient's consent, front desk or dentist calls or sends written notice to the treating orthodontic office describing exactly what component was removed or adjusted so their plan can be corrected at the next visit.\n\nWhy: The treating office owns the overall plan; unreported chairside changes can silently derail their tooth-movement sequence.\n\nRecord: treating office contacted, date, component change communicated",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the patient's treating orthodontic office",
          "why": "The treating office owns the overall plan; unreported chairside changes can silently derail their tooth-movement sequence."
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Orthodontic emergency — poking wire, loose bracket or band from outside treatment — A patient in fixed appliances from another office presents with a poking wire (a same-day courtesy relief visit, not a medical or dental emergency).",
      "title": "Orthodontic emergency — poking wire, loose bracket or band from outside treatment",
      "trigger": "A patient in fixed appliances from another office presents with a poking wire (a same-day courtesy relief visit, not a medical or dental emergency)",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        },
        {
          "kind": "regulation",
          "label": "FDA aligner device class II labeling",
          "source": "FDA aligner device class II labeling",
          "url": "https://www.fda.gov/"
        },
        {
          "kind": "generic",
          "label": "Case-selection and caregiver-consent workflow — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Case-selection and caregiver-consent workflow: generic functional equivalent"
          },
          "source": "Case-selection and caregiver-consent workflow — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "calo-011",
      "kind": "clinical",
      "materials": [
        "mixed-dentition exam records (photos, radiographs as indicated)",
        "habit appliance or crossbite appliance impressions/scan",
        "space maintainer inventory",
        "caregiver consent form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "caregiver",
        "specialist-referral",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist examines the child, notes whether the issue is a posterior or anterior crossbite, a thumb/finger/pacifier habit, or premature loss of a primary tooth causing space loss, with supporting photos and radiographs as indicated, and reviews medical history for any material allergy (for example nickel sensitivity) relevant to appliance fabrication.\n\nWhy: Each finding type has a different interceptive appliance and a different urgency for starting treatment during the mixed-dentition window.\n\nRecord: finding type, tooth/teeth involved, supporting images",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Complete a mixed-dentition exam and identify the finding",
          "why": "Each finding type has a different interceptive appliance and a different urgency for starting treatment during the mixed-dentition window."
        },
        {
          "detail": "Dentist judges complexity: a simple habit appliance or single-tooth space maintainer is commonly treated in-house; skeletal crossbites, complex space-loss cases, or anything outside the dentist's comfort and training goes to a specialist.\n\nWhy: Interceptive appliances range from routine (space maintainer) to specialist-level (skeletal expansion), and case selection is a clinical judgment the taxonomy places squarely with the treating dentist.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "in-house",
              "label": "Treat in-house"
            },
            {
              "goto": "s11",
              "id": "refer",
              "label": "Refer to a specialist"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this appropriate for in-house interceptive treatment or a specialist referral?",
          "why": "Interceptive appliances range from routine (space maintainer) to specialist-level (skeletal expansion), and case selection is a clinical judgment the taxonomy places squarely with the treating dentist."
        },
        {
          "detail": "Dentist selects the appliance appropriate to the finding: a habit-breaking appliance for a persistent thumb/finger habit, a crossbite corrector for a posterior or anterior crossbite, or a space maintainer for premature primary-tooth loss.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "habit",
              "label": "Habit-breaking appliance"
            },
            {
              "goto": "s4",
              "id": "crossbite",
              "label": "Crossbite-correction appliance"
            },
            {
              "goto": "s4",
              "id": "space",
              "label": "Space maintainer"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Select the appliance type for the finding"
        },
        {
          "detail": "Dentist explains the finding, the proposed appliance, expected wear duration, and risks/benefits to the caregiver; caregiver signs consent before any impressions are taken or appliance delivered.\n\nWhy: The patient is a minor, so informed consent is obtained from the caregiver, and treatment must not proceed without it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Caregiver consent before appliance impressions or delivery.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Caregiver consent before appliance impressions or delivery",
          "why": "The patient is a minor, so informed consent is obtained from the caregiver, and treatment must not proceed without it."
        },
        {
          "detail": "Assistant or dentist captures impressions or a digital scan of the arch, sends to the lab liaison for fabrication, and schedules a delivery appointment.\n\nWhy: Interceptive appliances are typically lab-fabricated to fit the child's arch precisely.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Take impressions or scan for the selected appliance",
          "why": "Interceptive appliances are typically lab-fabricated to fit the child's arch precisely."
        },
        {
          "detail": "Dentist fits the appliance, checks for sore spots, and reviews wear schedule, hygiene around the appliance, and what to do if it becomes loose or uncomfortable, with the caregiver present.\n\nWhy: Compliance with a habit or crossbite appliance depends heavily on the caregiver reinforcing wear at home.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Deliver the appliance and instruct caregiver and child on wear and hygiene",
          "why": "Compliance with a habit or crossbite appliance depends heavily on the caregiver reinforcing wear at home."
        },
        {
          "detail": "Front desk books a follow-up visit at the interval the dentist specifies to confirm habit cessation, crossbite correction progress, or space maintainer integrity.\n\nWhy: Interceptive appliances need periodic verification that the correction is progressing and the appliance is still fitting well as the child grows.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the follow-up recheck",
          "why": "Interceptive appliances need periodic verification that the correction is progressing and the appliance is still fitting well as the child grows."
        },
        {
          "detail": "Dentist assesses whether the habit has stopped, the crossbite has corrected, or the space is holding, versus needing continued wear or a plan change.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "resolved",
              "label": "Finding resolved, appliance can be discontinued"
            },
            {
              "goto": "s7",
              "id": "continue",
              "label": "Continued wear needed"
            },
            {
              "goto": "s11",
              "id": "escalate",
              "label": "Not resolving as expected — refer to specialist"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "At follow-up: is the finding resolved?"
        },
        {
          "detail": "Record the finding, appliance used, wear duration, and outcome (resolved / referred / ongoing) in the chart.\n\nRecord: finding, appliance type, wear duration, outcome",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the interceptive treatment outcome"
        },
        {
          "detail": "Interceptive orthodontic case closed or handed to specialist",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Interceptive orthodontic case closed or handed to specialist"
        },
        {
          "detail": "Dentist sends the exam findings, photos and radiographs to a specialist referral for evaluation, and front desk schedules the caregiver a follow-up to confirm the referral was completed.\n\nWhy: Complex interceptive cases benefit from specialist orthodontic evaluation before an appliance is fabricated.\n\nRecord: referral sent date, specialist name, records transmitted",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to a specialist with records",
          "why": "Complex interceptive cases benefit from specialist orthodontic evaluation before an appliance is fabricated."
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Interceptive orthodontics — habit appliances, crossbite correction, space regaining — A mixed-dentition child with a crossbite, thumb habit or space loss.",
      "title": "Interceptive orthodontics — habit appliances, crossbite correction, space regaining",
      "trigger": "A mixed-dentition child with a crossbite, thumb habit or space loss",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAO openly published guidance on treatment timing and retention",
          "source": "AAO openly published guidance on treatment timing and retention",
          "url": "https://www.aaoinfo.org/"
        },
        {
          "kind": "regulation",
          "label": "FDA aligner device class II labeling",
          "source": "FDA aligner device class II labeling",
          "url": "https://www.fda.gov/"
        },
        {
          "kind": "generic",
          "label": "White-spot monitoring and home-care coaching script — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "White-spot monitoring and home-care coaching script: generic functional equivalent"
          },
          "source": "White-spot monitoring and home-care coaching script — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clear-aligner-orthodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "calo-012",
      "kind": "clinical",
      "materials": [
        "fluoride varnish",
        "disclosing solution",
        "orthodontic-specific hygiene aids (interdental brushes, floss threaders or water flosser)",
        "intraoral camera for baseline photos"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Hygienist uses disclosing solution around brackets/attachments or aligner-contact areas, visually inspects for early white-spot lesions (chalky, opaque areas near the gingival margin of brackets), and takes intraoral photos to compare against the case's baseline.\n\nWhy: White-spot decalcification can begin within weeks of poor plaque control around fixed appliances or attachments, and catching it early is far easier to manage than after treatment ends.\n\nRecord: plaque disclosing findings, white-spot presence/location, comparison photos",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Examine plaque control and enamel appearance at the recall visit",
          "why": "White-spot decalcification can begin within weeks of poor plaque control around fixed appliances or attachments, and catching it early is far easier to manage than after treatment ends."
        },
        {
          "detail": "Hygienist classifies today's finding: no signs, heavy plaque but no white spots yet, or visible early white spots.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "low-risk",
              "label": "Good hygiene, no signs"
            },
            {
              "goto": "s6",
              "id": "elevated-risk",
              "label": "Heavy plaque, no white spots yet"
            },
            {
              "goto": "s8",
              "id": "active-lesion",
              "label": "Visible early white spots"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Assess decalcification risk from today's findings"
        },
        {
          "detail": "Hygienist reviews brushing/flossing technique around the appliance, applies fluoride varnish per the practice's standard interval, and confirms the next recall date.\n\nWhy: Consistent fluoride exposure strengthens enamel against the elevated caries risk that appliances create by trapping plaque.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Reinforce routine hygiene coaching and apply fluoride varnish",
          "why": "Consistent fluoride exposure strengthens enamel against the elevated caries risk that appliances create by trapping plaque."
        },
        {
          "detail": "Front desk books the next recall at the standard interval for active-orthodontic patients.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the patient's next active-orthodontic recall"
        },
        {
          "detail": "Decalcification monitoring visit closed",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Decalcification monitoring visit closed"
        },
        {
          "detail": "Hygienist demonstrates technique with interdental brushes, floss threaders or a water flosser at the specific plaque-retentive areas found today, dispenses the aids to the patient, and applies fluoride varnish.\n\nWhy: Generic brushing instruction is often insufficient around brackets and attachments; targeted coaching at the specific retentive spots changes behavior more reliably.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Provide targeted hygiene coaching and orthodontic-specific aids",
          "why": "Generic brushing instruction is often insufficient around brackets and attachments; targeted coaching at the specific retentive spots changes behavior more reliably."
        },
        {
          "detail": "Hygienist books the next recall sooner than the practice's standard active-orthodontic interval to recheck plaque control before it becomes a lesion.\n\nWhy: A shorter feedback loop catches whether the intensive coaching worked before decalcification sets in.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Shorten the recall interval for this patient",
          "why": "A shorter feedback loop catches whether the intensive coaching worked before decalcification sets in."
        },
        {
          "detail": "Hygienist flags the finding and photos to the dentist for review at the same visit or the earliest opportunity.\n\nWhy: Active decalcification is a clinical finding that affects the treatment plan and needs the treating dentist's evaluation, not just hygiene coaching alone.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Notify the treating dentist of the active white-spot finding",
          "why": "Active decalcification is a clinical finding that affects the treatment plan and needs the treating dentist's evaluation, not just hygiene coaching alone."
        },
        {
          "detail": "Dentist reviews the photos and findings, discusses with the patient (and caregiver if a minor) whether appliance modification, more frequent hygiene visits, or remineralization therapy is needed, and documents the plan.\n\nWhy: The dentist owns the decision on whether decalcification changes the orthodontic plan itself, such as pausing progression until hygiene improves.\n\nRecord: lesion location, severity, plan discussed with patient/caregiver",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist evaluates the lesion and treatment implications",
          "why": "The dentist owns the decision on whether decalcification changes the orthodontic plan itself, such as pausing progression until hygiene improves."
        }
      ],
      "subclass": "clear-aligner-and-gp-orthodontics",
      "summary": "Decalcification prevention and monitoring during orthodontic treatment — A patient in active orthodontics shows plaque accumulation or early white spots.",
      "title": "Decalcification prevention and monitoring during orthodontic treatment",
      "trigger": "A patient in active orthodontics shows plaque accumulation or early white spots",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 12,
      "frequency": "per-patient",
      "id": "ccdw-001",
      "kind": "clinical",
      "materials": [
        "intraoral scanner and wand",
        "disposable scanner sleeves/tips",
        "retractors",
        "air-water syringe and gauze",
        "operatory monitor for chairside review"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Retract cheeks and tongue, dry the teeth and gingiva with air, and remove excess saliva before starting the wand.\n\nWhy: Wet or reflective surfaces cause scan noise and voids that force a retake later.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate and dry the arch to be scanned",
          "why": "Wet or reflective surfaces cause scan noise and voids that force a retake later."
        },
        {
          "detail": "Sweep occlusal, then buccal, then lingual/palatal in overlapping passes per the scanner's guided pattern until the arch is fully captured on screen.\n\nWhy: A consistent sweep pattern minimizes stitching errors in the resulting mesh.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Scan the upper arch in the standard sweep pattern",
          "why": "A consistent sweep pattern minimizes stitching errors in the resulting mesh."
        },
        {
          "detail": "Repeat the occlusal/buccal/lingual sweep on the opposing arch.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Scan the lower arch in the standard sweep pattern"
        },
        {
          "detail": "Have the patient close in maximum intercuspation and scan the buccal segments in occlusion on both sides.\n\nWhy: The bite scan aligns the two arches so the design software can reproduce occlusal contacts.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Capture the bite registration scan",
          "why": "The bite scan aligns the two arches so the design software can reproduce occlusal contacts."
        },
        {
          "detail": "Confirm: no holes/voids in the mesh, margins fully captured if a prep is present, bite registration aligns cleanly, and color texture is legible for shade reference.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Run the on-screen quality check"
        },
        {
          "detail": "Dentist reviews the on-screen model before the patient is released from the chair.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "accept",
              "label": "Accept — quality sufficient for the intended restoration"
            },
            {
              "goto": "s10",
              "id": "retake",
              "label": "Retake — void, distortion or missing margin detected"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Scan acceptable to proceed?"
        },
        {
          "detail": "Save upper, lower and bite scans under the patient's record with the date, arch(es) scanned and intended use (crown/aligner/guard).",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Save and label the scan set in the patient record"
        },
        {
          "detail": "For an in-office restoration, hand the saved scan to the dentist for chairside design (see preparation-scan protocol). For aligner or lab cases, queue the scan for export.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to the design or send-out workflow"
        },
        {
          "detail": "Scan capture complete",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Scan capture complete"
        },
        {
          "detail": "Re-dry and re-isolate the flagged area, then rescan only that segment and re-merge into the existing mesh rather than restarting the whole arch.\n\nWhy: Partial rescan is faster and avoids re-annoying the patient with a full redo.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Retake the affected region only",
          "why": "Partial rescan is faster and avoids re-annoying the patient with a full redo."
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Intraoral scan — full arch, opposing and bite registration with quality check — A digital impression is needed for a restoration, aligner records or a night guard.",
      "title": "Intraoral scan — full arch, opposing and bite registration with quality check",
      "trigger": "A digital impression is needed for a restoration, aligner records or a night guard",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "ccdw-002",
      "kind": "clinical",
      "materials": [
        "intraoral scanner",
        "retraction cord or tissue management material",
        "design workstation/monitor",
        "gingival hemostatic agent"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Place retraction cord or apply tissue displacement so the finish line is dry and clearly visible before scanning.\n\nWhy: An obscured margin produces a design with a poor-fitting or over/under-contoured margin.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Manage soft tissue for margin visibility",
          "why": "An obscured margin produces a design with a poor-fitting or over/under-contoured margin."
        },
        {
          "detail": "Capture the prep tooth, both adjacent teeth for contact points, the full opposing arch, and a bite registration.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Scan the preparation, adjacent teeth and opposing arch"
        },
        {
          "detail": "Confirm the software's margin line follows the true finish line 360 degrees around the prep with no gaps or jumps.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Verify the finish line is fully traced on screen"
        },
        {
          "detail": "Dentist reviews the automatically or manually traced margin line before design proceeds.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accept-margin",
              "label": "Accept — margin line is continuous and accurate"
            },
            {
              "goto": "s11",
              "id": "retrace",
              "label": "Retrace or rescan — margin line is inaccurate or incomplete"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the traced margin acceptable?"
        },
        {
          "detail": "Select restoration type and tooth anatomy library, then let the design software propose contours, contacts and occlusion based on the scan.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Generate the proposed restoration design"
        },
        {
          "detail": "Check interproximal contacts, occlusal contacts against the opposing arch, marginal fit line, and overall anatomy before accepting.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Review proposed contacts, contour, occlusion and margin fit"
        },
        {
          "detail": "The treating dentist must explicitly approve the design as final before it is sent to milling or printing — the design becomes the physical restoration with no further clinical check until try-in.\n\nWhy: This is the last point a design error can be caught before material is committed and time is spent milling it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the final design before it is sent to production.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the final design before it is sent to production",
          "why": "This is the last point a design error can be caught before material is committed and time is spent milling it."
        },
        {
          "detail": "Log tooth number, restoration type, material selection, and that the dentist approved the final chairside design.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Record design approval in the patient chart"
        },
        {
          "detail": "Send the finalized design file to the block-selection-and-milling protocol for material selection and production.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off the approved design to milling/printing"
        },
        {
          "detail": "Design approved and queued for production",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Design approved and queued for production"
        },
        {
          "detail": "Adjust tissue management if needed, then either hand-correct the margin line in the design software or rescan the affected area.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Manually retrace the margin or rescan the region"
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Preparation scan, margin marking and design approval — A crown or onlay preparation is complete and will be designed chairside.",
      "title": "Preparation scan, margin marking and design approval",
      "trigger": "A crown or onlay preparation is complete and will be designed chairside",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "per-patient",
      "id": "ccdw-003",
      "kind": "clinical",
      "materials": [
        "milling unit",
        "restorative blocks matched to shade/material",
        "milling burs/tools",
        "block holder/mandrel"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull a block of the material specified in the approved design (e.g., glass-ceramic or zirconia) matching the recorded shade.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Select the block matching material and shade"
        },
        {
          "detail": "Record the block's lot/batch number, material and shade against the job ticket for traceability.\n\nWhy: If a restoration later fails or a material recall occurs, the lot must be traceable back to the specific patient.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Log the block lot number against the patient job",
          "why": "If a restoration later fails or a material recall occurs, the lot must be traceable back to the specific patient."
        },
        {
          "detail": "Confirm the current bur/tool set has cycles remaining below the manufacturer's replacement threshold; swap any tool at or past its rated life.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Check milling tool life before starting the job"
        },
        {
          "detail": "Are the milling tools within their usable life?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "tools-ok",
              "label": "Yes — proceed with the current tool set"
            },
            {
              "goto": "s10",
              "id": "tools-worn",
              "label": "No — replace worn tool(s) first"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Are the milling tools within their usable life?"
        },
        {
          "detail": "Secure the block in the holder, load the approved design file into the mill's queue, and start the cycle.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Load the block and start the milling job"
        },
        {
          "detail": "Wait for the milling cycle to complete; periodically check that the unit is running without an error or collision alarm.\n\nWhy: Catching a mid-cycle fault early avoids wasting the block and losing chair time.",
          "id": "s6",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 1080,
          "title": "Mill cycle running",
          "why": "Catching a mid-cycle fault early avoids wasting the block and losing chair time."
        },
        {
          "detail": "Check for chips, incomplete milling, or connector breakage before moving to post-processing (sprue removal, try-in prep).",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Unload and inspect the milled restoration"
        },
        {
          "detail": "Send glass-ceramic/zirconia restorations to the crystallization-or-sintering-cycle protocol; hand fully cured materials directly to same-visit delivery.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to the appropriate next step"
        },
        {
          "detail": "Milling complete",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Milling complete"
        },
        {
          "detail": "Swap out the tool(s) past their rated cycle count and reset the tool-life counter, then re-run the tool check.\n\nWhy: Worn tools produce undersized or rough-fitting restorations that fail at try-in.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Replace the worn milling tool(s)",
          "why": "Worn tools produce undersized or rough-fitting restorations that fail at try-in."
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Block and material selection and milling with tool-life check — The design is approved and the restoration will be milled in-office.",
      "title": "Block and material selection and milling with tool-life check",
      "trigger": "The design is approved and the restoration will be milled in-office",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "per-patient",
      "id": "ccdw-004",
      "kind": "clinical",
      "materials": [
        "chairside furnace",
        "furnace tray/pins",
        "heat-resistant gloves/tongs",
        "polishing/glazing supplies",
        "shade-matched glaze or stain (if applicable)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Carefully separate the restoration from its milling sprue using the appropriate bur or cutting disc, then smooth the connection point.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Remove milling sprues/connectors"
        },
        {
          "detail": "Choose the crystallization program for glass-ceramic or the sintering program for zirconia exactly as specified by the block manufacturer's instructions for use.\n\nWhy: Using the wrong temperature/time program can under-fire (weak restoration) or over-fire (distorted restoration) the material.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Select the correct furnace program for the material",
          "why": "Using the wrong temperature/time program can under-fire (weak restoration) or over-fire (distorted restoration) the material."
        },
        {
          "detail": "Position the restoration on the correct firing tray or support pins so it does not contact the furnace chamber walls.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Place the restoration on the firing tray/pins"
        },
        {
          "detail": "Run the selected program to completion for the exact duration shown on the furnace's program display — glass-ceramic crystallization and zirconia sintering cycles run for materially different lengths of time, so do not assume a fixed duration. Do not open the furnace door mid-cycle.\n\nWhy: Interrupting the cycle can leave the restoration under-processed and structurally weak, and zirconia sintering in particular can run well beyond a glass-ceramic crystallization cycle's length.\n\nCadence: an unspecified interval (no valid timer duration in source — downgraded from a timer step).",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Furnace cycle running",
          "why": "Interrupting the cycle can leave the restoration under-processed and structurally weak, and zirconia sintering in particular can run well beyond a glass-ceramic crystallization cycle's length."
        },
        {
          "detail": "Allow the restoration to cool per the manufacturer's cool-down instructions before removing it with heat-resistant tongs.\n\nWhy: Removing a hot ceramic restoration too soon risks thermal shock cracking and burn injury.",
          "id": "s5",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 480,
          "title": "Controlled cool-down before handling",
          "why": "Removing a hot ceramic restoration too soon risks thermal shock cracking and burn injury."
        },
        {
          "detail": "Check for cracks, incomplete color/translucency uptake, or warping before proceeding to polish/glaze.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Inspect the fired restoration"
        },
        {
          "detail": "Apply staining/glaze and re-fire if a glaze cycle is specified, or hand-polish per the material's finishing protocol.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Polish or glaze as specified for the case"
        },
        {
          "detail": "Record the program used, cycle time and any anomaly (e.g., crack, re-fire) in the equipment log and the patient job ticket.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Log the furnace cycle against the job"
        },
        {
          "detail": "Pass the cooled, inspected restoration to the same-visit-delivery protocol.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the finished restoration to the dentist for delivery"
        },
        {
          "detail": "Post-processing complete",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Post-processing complete"
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Crystallization or sintering furnace cycle and post-processing — A milled glass-ceramic or zirconia restoration comes off the mill.",
      "title": "Crystallization or sintering furnace cycle and post-processing",
      "trigger": "A milled glass-ceramic or zirconia restoration comes off the mill",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "per-patient",
      "id": "ccdw-005",
      "kind": "clinical",
      "materials": [
        "articulating paper",
        "floss",
        "try-in paste (if applicable)",
        "cement or bonding kit matched to material",
        "rubber dam or isolation system",
        "occlusal adjustment burs and polishers"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Seat the restoration without cement and check seating, marginal fit, and interproximal contacts with floss.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Try in the restoration on the prepared tooth"
        },
        {
          "detail": "Does the restoration seat and fit correctly?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "fit-ok",
              "label": "Yes — margins closed, contacts correct, no rocking"
            },
            {
              "goto": "s11",
              "id": "fit-fail",
              "label": "No — open margin, poor contact, or does not seat"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the restoration seat and fit correctly?"
        },
        {
          "detail": "Have the patient bite on articulating paper in maximum intercuspation and lateral/protrusive movements; adjust and repolish any high spots.\n\nWhy: An undetected high spot causes post-operative pain and can fracture the restoration or opposing tooth.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check and adjust occlusal contacts",
          "why": "An undetected high spot causes post-operative pain and can fracture the restoration or opposing tooth."
        },
        {
          "detail": "Compare the seated restoration to adjacent teeth in natural light with the patient able to view it before committing to permanent cementation.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm final shade and esthetics with the patient present"
        },
        {
          "detail": "The treating dentist confirms fit, occlusion and esthetics are acceptable and documents approval before cement is mixed — this is the last reversible point before the restoration is permanently bonded.\n\nWhy: Cementation is not easily reversible; a licensed clinician must own this specific go/no-go decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off to proceed with permanent cementation.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off to proceed with permanent cementation",
          "why": "Cementation is not easily reversible; a licensed clinician must own this specific go/no-go decision."
        },
        {
          "detail": "Isolate the field, prepare the tooth and restoration surfaces per the material's bonding protocol, seat the restoration, and hold under pressure per the cement's working time.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Isolate and cement or bond the restoration"
        },
        {
          "detail": "Floss all contacts to confirm no residual cement, and re-check occlusion once cement has set.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Remove excess cement and re-verify contacts and occlusion"
        },
        {
          "detail": "Document tooth number, material, shade, cement/bonding agent used, and final occlusal notes.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Record delivery in the patient chart"
        },
        {
          "detail": "Explain any temporary sensitivity to expect, chewing precautions if applicable, and when to call if something feels off.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Give the patient post-delivery care instructions"
        },
        {
          "detail": "Restoration delivered",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Restoration delivered"
        },
        {
          "detail": "Dentist judges whether a minor adjustment (contact polishing, internal relief) resolves the issue or whether the restoration must be re-designed and remade.",
          "forks": [
            {
              "advised": true,
              "goto": "s1",
              "id": "minor-adjust",
              "label": "Minor chairside adjustment"
            },
            {
              "goto": "s12",
              "id": "remake",
              "label": "Remake — rescan and redesign required"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Can the fit issue be corrected chairside?"
        },
        {
          "detail": "Restart the digital design workflow with a fresh preparation scan rather than force-fitting a flawed restoration.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to preparation-scan-and-margin-marking for a remake"
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Same-visit try-in, staining, glazing and delivery of a milled restoration — The restoration is finished and the patient is still in the chair.",
      "title": "Same-visit try-in, staining, glazing and delivery of a milled restoration",
      "trigger": "The restoration is finished and the patient is still in the chair",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "ccdw-006",
      "kind": "clinical",
      "materials": [
        "3D printer",
        "print resin matched to the intended use (model/guide/appliance/provisional)",
        "isopropyl alcohol wash station",
        "post-cure light unit",
        "nitrile gloves and eye protection"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the file is queued with the resin profile for its use — biocompatible surgical-guide resin, model resin, or appliance/night-guard resin are not interchangeable.\n\nWhy: A model-only resin used for an appliance the patient wears is a biocompatibility risk.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Select the resin matched to the intended use",
          "why": "A model-only resin used for an appliance the patient wears is a biocompatibility risk."
        },
        {
          "detail": "Check the sliced file's orientation and support placement to avoid warping and to keep supports off critical surfaces (fit surfaces, margins).",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm print orientation and support structures"
        },
        {
          "detail": "Load the correct resin tank/cartridge, start the print, and log the patient, use case and resin lot on the job ticket.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Load resin, start the print job, and log it"
        },
        {
          "detail": "Allow the print to complete; check periodically for a failed layer or resin-level warning.",
          "id": "s4",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 2100,
          "title": "Print cycle running"
        },
        {
          "detail": "Assistant checks the finished job against the print log before moving to post-processing.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "print-ok",
              "label": "Print completed cleanly"
            },
            {
              "goto": "s14",
              "id": "print-failed",
              "label": "Failed layer or resin-level fault detected — abort and restart"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Did the print complete without a failed layer or resin-level fault?"
        },
        {
          "detail": "Wash the part in isopropyl alcohol per the resin's specified wash time and method to remove uncured resin.\n\nWhy: Uncured resin left on the surface is a chemical/skin irritation hazard and interferes with final cure.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Wash the printed part",
          "why": "Uncured resin left on the surface is a chemical/skin irritation hazard and interferes with final cure."
        },
        {
          "detail": "Post-cure the washed and dried part in the cure unit for the resin's specified time and wavelength.",
          "id": "s7",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 600,
          "title": "Post-cure the part"
        },
        {
          "detail": "Clip supports and smooth contact points, being careful not to alter fit surfaces or the guide's intended contact with teeth.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Remove support structures and finish edges"
        },
        {
          "detail": "Seat the printed model/guide/appliance on the printed or physical model to confirm it seats fully with no obvious distortion.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Bench-check fit against the model or scan before the patient appointment"
        },
        {
          "detail": "A model that never enters the patient's mouth needs no reprocessing. A night guard or provisional contacts oral tissue and needs disinfection. A surgical guide contacts bone/blood during an implant osteotomy and is a critical item requiring sterilization or the resin manufacturer's validated critical-item reprocessing method.\n\nWhy: Nothing between finishing the printed part and the dentist placing it in the patient's mouth currently reprocesses it — a bench fit-check is not infection control.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "model-only",
              "label": "Model only — never contacts the patient, no reprocessing needed"
            },
            {
              "goto": "s15",
              "id": "night-guard-provisional",
              "label": "Night guard or provisional — disinfect before try-in"
            },
            {
              "goto": "s16",
              "id": "surgical-guide",
              "label": "Surgical guide — sterilize or apply validated critical-item reprocessing"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "assistant",
          "title": "Does this printed item need disinfection or sterilization before it contacts the patient?",
          "why": "Nothing between finishing the printed part and the dentist placing it in the patient's mouth currently reprocesses it — a bench fit-check is not infection control."
        },
        {
          "detail": "For a surgical guide, night guard or provisional, the treating dentist tries it on the patient and confirms fit, stability and intended function before it is finalized for use.\n\nWhy: A surgical guide or appliance that fits poorly can misdirect a procedure or injure soft tissue — this is a licensed clinical check, not a bench check.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist verifies fit and intended use before the patient uses the appliance/guide.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist verifies fit and intended use before the patient uses the appliance/guide",
          "why": "A surgical guide or appliance that fits poorly can misdirect a procedure or injure soft tissue — this is a licensed clinical check, not a bench check."
        },
        {
          "detail": "Log the item type, resin lot, and dentist fit-verification outcome in the patient record.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Record the printed item in the patient chart"
        },
        {
          "detail": "Printed item verified and ready for use",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Printed item verified and ready for use"
        },
        {
          "detail": "Discard the partially printed part, address the fault (top off/replace resin, re-orient or re-slice the file if the failure was structural), and restart the print job from the beginning.\n\nWhy: Continuing post-processing on a part with a failed layer produces a restoration or guide with a hidden structural defect.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Abort the failed job, re-slice or refill, and restart the print",
          "why": "Continuing post-processing on a part with a failed layer produces a restoration or guide with a hidden structural defect."
        },
        {
          "detail": "Disinfect the night guard or provisional per the resin/appliance manufacturer's instructions for use before the dentist tries it on the patient.\n\nWhy: A printed appliance that contacts oral mucosa and saliva must be disinfected before intraoral placement, even for a same-visit bench-checked item.",
          "id": "s15",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the appliance before it is tried in the patient's mouth",
          "why": "A printed appliance that contacts oral mucosa and saliva must be disinfected before intraoral placement, even for a same-visit bench-checked item."
        },
        {
          "detail": "Sterilize the guide, or apply the resin manufacturer's validated critical-item reprocessing method if the resin is not autoclave-stable, before it is used for an implant osteotomy. Confirm on the checklist that this step is complete before try-in on the patient.\n\nWhy: A surgical guide contacts bone and blood during an implant procedure and is a critical item under standard infection-control classification — it cannot go from the printer bench to the patient's mouth unsterilized.",
          "id": "s16",
          "kind": "step",
          "role": "assistant",
          "title": "Sterilize the surgical guide or apply the validated critical-item reprocessing method",
          "why": "A surgical guide contacts bone and blood during an implant procedure and is a critical item under standard infection-control classification — it cannot go from the printer bench to the patient's mouth unsterilized."
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "In-office 3D printing — models, surgical guides, night guards, provisionals — with post-processing checklist — A printable file is approved and the printer is available.",
      "title": "In-office 3D printing — models, surgical guides, night guards, provisionals — with post-processing checklist",
      "trigger": "A printable file is approved and the printer is available",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "weekly",
      "id": "ccdw-007",
      "kind": "clinical",
      "materials": [
        "manufacturer calibration target/tile for the scanner",
        "lens/optics cleaning wipes",
        "mill chamber vacuum/brush",
        "printer vat and build-plate cleaning kit",
        "maintenance log (paper or digital)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Review the maintenance log to see which of the scanner, mill and printer are due on their weekly schedule, and note any reported drift/artifact complaints since the last cycle.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Check which devices are due and why"
        },
        {
          "detail": "Wipe the scanner wand lens per the manufacturer's cleaning instructions, then scan the calibration target/tile and confirm the software reports a pass.\n\nWhy: A dirty lens is the most common cause of scan noise mistaken for a hardware fault.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Clean the scanner optics and run the calibration target",
          "why": "A dirty lens is the most common cause of scan noise mistaken for a hardware fault."
        },
        {
          "detail": "Did the scanner pass calibration?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "scanner-pass",
              "label": "Pass — continue to mill maintenance"
            },
            {
              "goto": "s8",
              "id": "scanner-fail",
              "label": "Fail — escalate"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Did the scanner pass calibration?"
        },
        {
          "detail": "Vacuum/brush milling debris from the chamber, check coolant/spray reservoir level, inspect the spindle and tool holders for wear, and confirm the tool-life counters match the physical tool age.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Clean and inspect the milling unit"
        },
        {
          "detail": "Filter or replace the resin vat if clouded/scratched, clean the build plate, and check the light engine/screen for visible defects per the manufacturer's schedule.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Clean and inspect the 3D printer"
        },
        {
          "detail": "Record date, devices serviced, calibration pass/fail results, and any parts replaced in the maintenance log.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Log the maintenance cycle"
        },
        {
          "detail": "Weekly calibration and maintenance complete",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Weekly calibration and maintenance complete"
        },
        {
          "detail": "Take the scanner out of clinical use for new preparations until the failure is resolved, contact the device's support line with the calibration error details, and record the escalation on the maintenance log so it is tracked independently of the mill/printer cycle.\n\nWhy: Using an out-of-calibration scanner for a preparation produces a restoration that will not fit — but a scanner-only failure must not also skip the unrelated mill and printer maintenance for the week.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Escalate a persistent calibration failure to the equipment vendor or IT support",
          "why": "Using an out-of-calibration scanner for a preparation produces a restoration that will not fit — but a scanner-only failure must not also skip the unrelated mill and printer maintenance for the week."
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Scanner, mill and printer calibration and maintenance log — Weekly maintenance is due, or scans show drift or artifacts.",
      "title": "Scanner, mill and printer calibration and maintenance log",
      "trigger": "Weekly maintenance is due, or scans show drift or artifacts",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 (Quality System Regulation) / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback) — generic functional equivalent; OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "OSHA 29 CFR 1910.1200 Scope and Application: 'This section requires chemical manufacturers or importers to classify the hazards of chemicals which they produce or import, and all employers to provide information to their employees about the hazardous chemicals to which they are exposed, by means of a hazard communication program, labels and other forms of warning, safety data sheets.' No provision in this standard addresses intraoral scanning, margin design, milling sequence, furnace/sintering cycles, restoration delivery, 3D-printing post-processing, equipment calibration, or workflow fallback procedures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1200 (Hazard Communication) — resin, dust and solvent hazards",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
            }
          },
          "source": "In-office CAD/CAM chairside clinical workflow procedure (scanning, design, milling, sintering, delivery, printing, calibration, fallback); OSHA Hazard Communication governs chemical labeling/SDS, not these clinical steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "ccdw-008",
      "kind": "clinical",
      "materials": [
        "conventional impression material and trays (backup stock)",
        "provisional material and shell/matrix",
        "temporary cement",
        "IT vendor/support contact list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Determine whether the failure is the scanner (hardware/software), the design software, or the mill/printer, and whether a quick fix (restart, reconnect) is possible.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Identify what failed"
        },
        {
          "detail": "Can the issue be resolved in under a few minutes chairside?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "quick-fix",
              "label": "Yes — restart/reconnect resolves it"
            },
            {
              "goto": "s6",
              "id": "no-quick-fix",
              "label": "No — will take longer than the patient can reasonably wait"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Can the issue be resolved in under a few minutes chairside?"
        },
        {
          "detail": "Return to the point of interruption in the intraoral-scan, preparation-scan or milling protocol.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Resume the interrupted digital protocol"
        },
        {
          "detail": "Record which device briefly failed, the approximate downtime, and the quick-fix action taken (restart/reconnect) so failure-rate and time-lost metrics stay accurate.\n\nWhy: A transient failure that is fixed in minutes still needs to count toward the monthly failure-rate and time-lost metrics this protocol tracks.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Log the brief interruption and quick fix",
          "why": "A transient failure that is fixed in minutes still needs to count toward the monthly failure-rate and time-lost metrics this protocol tracks."
        },
        {
          "detail": "Digital workflow resumed — no fallback needed",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Digital workflow resumed — no fallback needed"
        },
        {
          "detail": "Explain plainly that the digital equipment is temporarily unavailable and describe the conventional-impression or provisional-and-return-visit alternative.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Inform the patient of the delay and the alternative plan"
        },
        {
          "detail": "The treating dentist decides whether to take a conventional impression and proceed same-visit via a lab, or place a provisional and reschedule for the digital workflow — and documents the reason and the plan chosen.\n\nWhy: Switching the treatment pathway mid-procedure is a clinical decision with downstream billing and scheduling consequences, so it needs an explicit licensed decision on record, not a default.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist decides and documents the fallback plan.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist decides and documents the fallback plan",
          "why": "Switching the treatment pathway mid-procedure is a clinical decision with downstream billing and scheduling consequences, so it needs an explicit licensed decision on record, not a default."
        },
        {
          "detail": "Which fallback path was chosen?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "conventional",
              "label": "Conventional impression, send to an outside lab"
            },
            {
              "goto": "s13",
              "id": "provisional-return",
              "label": "Place a provisional and reschedule for the digital workflow"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Which fallback path was chosen?"
        },
        {
          "detail": "Select an appropriately sized tray, take the impression per standard technique, and inspect it for voids or pulls before sending to the lab.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Take a conventional impression"
        },
        {
          "detail": "Record which device failed, time lost, the fallback path chosen, and file an equipment ticket if the device needs vendor/IT service.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Log the equipment failure and the fallback taken"
        },
        {
          "detail": "Report the failure with error details so the device can be repaired before its next scheduled use, and flag it out of service in the meantime.",
          "id": "s11",
          "kind": "step",
          "role": "it-vendor",
          "title": "Notify IT or the equipment vendor of the failure"
        },
        {
          "detail": "Fallback executed and equipment failure logged",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Fallback executed and equipment failure logged"
        },
        {
          "detail": "Fabricate a provisional from the pre-prep shape or a shell/matrix, adjust occlusion, and cement with temporary cement.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Fabricate and seat a provisional restoration"
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Digital workflow failure — fallback to conventional impression or provisional — The scanner, software or mill fails mid-appointment.",
      "title": "Digital workflow failure — fallback to conventional impression or provisional",
      "trigger": "The scanner, software or mill fails mid-appointment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Vendor chairside software workflows — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent of vendor chairside software workflows (never reproduced)"
          },
          "source": "Vendor chairside software workflows — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 820 / device instructions for use for mills, printers and resins",
          "source": "FDA 21 CFR 820 / device instructions for use for mills, printers and resins",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-820"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 (resin and dust hazards)",
          "source": "OSHA 29 CFR 1910.1200 (resin and dust hazards)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        },
        {
          "kind": "generic",
          "label": "Shade matching is time-sensitive to tooth hydration and ambient light — generic clinical-photography and shade-taking practice (take shade first, before rubber dam/prep dehydrates enamel; neutralize ambient color with gray card or off overhead light; capture middle third of the tooth at eye level)",
          "source": "Shade matching is time-sensitive to tooth hydration and ambient light — generic clinical-photography and shade-taking practice (take shade first, before rubber dam/prep dehydrates enamel; neutralize ambient color with gray card or off overhead light; capture middle third of the tooth at eye level)"
        }
      ],
      "class": "chairside-cadcam",
      "department": "clinical",
      "duration_min": 12,
      "frequency": "per-patient",
      "id": "ccdw-009",
      "kind": "clinical",
      "materials": [
        "digital shade-capture device",
        "shade tab guide (visual)",
        "cotton rolls or gauze",
        "polarizing lens/hood for the shade device if supplied",
        "lab prescription form",
        "chair light dimmer or off switch"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the treatment plan for an esthetic restoration (crown, veneer, bonding, single-tooth replacement) in a visible zone. Confirm with the dentist which tooth/teeth need shade documentation before any prep, whitening, or rubber-dam placement begins.\n\nWhy: Shade must be captured before the tooth dehydrates or is isolated — dehydrated enamel reads artificially light/opaque and produces a mismatched restoration.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the case needs a recorded shade",
          "why": "Shade must be captured before the tooth dehydrates or is isolated — dehydrated enamel reads artificially light/opaque and produces a mismatched restoration."
        },
        {
          "detail": "1) Dim or turn off the overhead operatory light and any colored wall/monitor light near the chair. 2) Remove lipstick, bibs, or brightly colored drapes from the patient's visual field near the mouth. 3) Have the patient rinse and let the tooth reach normal hydration (do not shade immediately after a scale/polish or after the patient has been open-mouthed and drying for more than a minute). 4) Seat the patient upright at eye level with the operator.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Prepare the environment for accurate color capture"
        },
        {
          "detail": "Confirm the digital shade device shows current calibration status per its instructions for use before using it for this case.\n\nWhy: An uncalibrated device produces a numerically confident but wrong shade value, which is worse than no digital reading because it is trusted uncritically downstream.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Verify the shade-capture device is calibrated and ready",
          "why": "An uncalibrated device produces a numerically confident but wrong shade value, which is worse than no digital reading because it is trusted uncritically downstream."
        },
        {
          "detail": "Assistant confirms whether the device's calibration status is current before it is used for this case.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "calibrated",
              "label": "Calibrated — proceed with the digital reading"
            },
            {
              "goto": "s14",
              "id": "overdue",
              "label": "Overdue — stop and route to the scanner/mill/printer calibration protocol"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the shade device within its calibration window?"
        },
        {
          "detail": "Position the device per its instructions for use against the middle third of the target tooth (avoiding incisal translucency and cervical zones), capture the reading, and repeat once at a second position on the same tooth to check for a consistent result.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Capture the digital shade reading"
        },
        {
          "detail": "Hold the two or three nearest visual shade tabs from the guide against the tooth at the same middle-third position, in the same dimmed lighting, and compare against the digital reading. Note agreement or the direction of any disagreement (e.g., digital reads lighter/more chromatic than the visual tab).\n\nWhy: Digital devices can be thrown off by translucency, hydration, or ambient reflectance; a human visual check catches outlier readings before they reach the lab.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Cross-check against a physical shade tab guide",
          "why": "Digital devices can be thrown off by translucency, hydration, or ambient reflectance; a human visual check catches outlier readings before they reach the lab."
        },
        {
          "detail": "The dentist decides whether the two methods are close enough to proceed or whether a third reference point is needed.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "agree",
              "label": "Digital and visual shade agree (or are within an acceptable range)"
            },
            {
              "goto": "s15",
              "id": "disagree",
              "label": "Digital and visual shade disagree meaningfully"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Do the digital reading and the visual check agree?"
        },
        {
          "detail": "Confirm the patient's on-file consent covers clinical photographs used for treatment and lab communication before the shade photo is taken. If no consent is on file, obtain it before the camera is used at all.\n\nWhy: Clinical photographs are PHI and require the same consent standard as any other image capture of the patient — the gate belongs before capture, not before storage.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent covers clinical photography before the camera is used.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "assistant",
          "title": "Confirm consent covers clinical photography before the camera is used",
          "why": "Clinical photographs are PHI and require the same consent standard as any other image capture of the patient — the gate belongs before capture, not before storage."
        },
        {
          "detail": "Take a close-up photo of the target tooth with the selected shade tab held directly adjacent to it, same lighting, same framing, for the lab to reference alongside the numeric shade call.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Photograph the tooth next to the chosen shade tab"
        },
        {
          "detail": "The dentist reviews the digital reading, the visual cross-check, and the photo, then signs off on the final shade to go on the lab prescription. This sign-off is required before the prescription is finalized, regardless of how confident the digital reading appeared.\n\nWhy: The restoration is a clinical and financial commitment; a device output alone never becomes the shade of record without a licensed clinician's confirmation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the final shade call before lab submission.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the final shade call before lab submission",
          "why": "The restoration is a clinical and financial commitment; a device output alone never becomes the shade of record without a licensed clinician's confirmation."
        },
        {
          "detail": "Enter the final shade call, the digital reading value, the tab used for visual cross-check, and the reference photo into the patient's clinical record and the lab prescription form, along with the date and the dentist's sign-off.\n\nRecord: final shade value, digital device reading, visual tab reference, cross-check photo, dentist sign-off, and date — filed in the patient chart and lab prescription",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Document the shade in the patient record and lab prescription"
        },
        {
          "detail": "If the restoration is fabricated in-office, hand the shade record to whoever runs the chairside design/mill step. If it is going to an outside lab, attach the shade record and photo to the outbound case.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off the shade record to the fabrication path"
        },
        {
          "detail": "The case is ready to proceed to design, milling, or lab shipment with a documented, dentist-confirmed shade.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Shade capture and cross-check complete"
        },
        {
          "detail": "Take the shade device out of clinical use for this case and route it to the calibration and maintenance protocol before it is used again.\n\nWhy: Using an out-of-calibration device for a shade call risks a remake that a visual-only comparison would have caught.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to the scanner/mill/printer calibration protocol",
          "why": "Using an out-of-calibration device for a shade call risks a remake that a visual-only comparison would have caught."
        },
        {
          "detail": "Re-capture the digital reading at a different tooth position, and/or bring in a second visual tab comparison under natural window light if available. Record both readings and the dentist's final called shade with a note on which method was trusted and why.\n\nWhy: A documented rationale protects against a remake dispute with the lab and gives the next visit's provider context if the case is revisited.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Resolve the disagreement with a third data point",
          "why": "A documented rationale protects against a remake dispute with the lab and gives the next visit's provider context if the case is revisited."
        }
      ],
      "subclass": "chairside-cadcam-and-digital-workflow",
      "summary": "Digital shade capture and cross-check with visual shade tabs — An esthetic restoration is planned and the shade must be recorded before dehydration.",
      "title": "Digital shade capture and cross-check with visual shade tabs",
      "trigger": "An esthetic restoration is planned and the shade must be recorded before dehydration",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "SOAP note content/timing; itemized informed-consent elements; AI-scribe clinician sign-off before charting — generic functional equivalent (standard-of-care/state dental-board recordkeeping practice, not this HIPAA section)",
          "repaired": {
            "action": "generic",
            "evidence": "'A covered entity must retain the documentation required by paragraph (j)(1) of this section for six years from the date of its creation or the date when it last was in effect, whichever is later.' Documentation required by the Privacy Rule (policies/procedures, Privacy Official designation, training records, complaints, sanctions, mitigation) is what §164.530 actually requires retained. Nothing in this text addresses same-day SOAP signing, informed-consent element checklists, or scribe sign-off workflow.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.530 (documentation)",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
            }
          },
          "source": "No federal authority found for the specific content requirements. 45 CFR §164.530 (HIPAA Privacy Rule administrative requirements) mandates a covered entity's OWN 6-year retention of its privacy-compliance paperwork (policies, workforce training, sanctions, complaints) — it does not require same-day-signed SOAP notes, itemized informed-consent elements, or clinician sign-off on an AI-drafted note before it enters the record. These are dental-recordkeeping/standard-of-care matters (state dental board practice-act rules), not cached or verified in this repo — generic functional equivalent"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "source": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "url": "https://www.dbc.ca.gov/formspubs/lawbook_dental.pdf"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (in-repo SOAP note)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (in-repo SOAP note)"
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 8,
      "frequency": "per-patient",
      "id": "cdoc-001",
      "kind": "operational",
      "materials": [
        "chart / practice management system note template",
        "clinical findings from the encounter",
        "radiographs or images taken that visit"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note the encounter has concluded and the chart is ready for the SOAP note (Subjective, Objective, Assessment, Plan).\n\nWhy: A note written from memory hours later loses detail and accuracy.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Encounter ends",
          "why": "A note written from memory hours later loses detail and accuracy."
        },
        {
          "detail": "Subjective (patient-reported complaint/history), Objective (exam findings, vitals, radiographic findings), Assessment (diagnosis or working diagnosis), Plan (treatment rendered today and next steps).\n\nRecord: SOAP note draft in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Draft the four SOAP elements"
        },
        {
          "detail": "Was a consent or refusal form used today?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — link the consent/refusal record"
            },
            {
              "goto": "s5",
              "id": "no",
              "label": "No related consent/refusal today"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Was a consent or refusal form used today?"
        },
        {
          "detail": "Add the id or date of the linked consent/refusal record into today's SOAP note.\n\nRecord: Reference to the linked consent/refusal record id in the note",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Cross-reference the consent or refusal record"
        },
        {
          "detail": "Log anesthetic type/amount, any materials with lot numbers, and any medications administered or prescribed.\n\nWhy: Materials and lot numbers support recall in the event of a product issue.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Record materials, medications and lot numbers used",
          "why": "Materials and lot numbers support recall in the event of a product issue."
        },
        {
          "detail": "Read the full note end to end; confirm tooth numbers, findings and plan match what was actually done.\n\nWhy: The signer is attesting the record is accurate, not merely present.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Review the completed draft for accuracy",
          "why": "The signer is attesting the record is accurate, not merely present."
        },
        {
          "detail": "The treating dentist (or supervising dentist for hygienist/assistant-authored entries) signs the note electronically before end of day.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before the note is final.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before the note is final"
        },
        {
          "detail": "Before closing the schedule for the day, the office manager (generic functional equivalent role) runs a report of any unsigned notes and flags them to the treating provider.\n\nWhy: Catches notes that slipped through before they age past same-day.",
          "id": "s8",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 900,
          "title": "End-of-day unsigned-note sweep",
          "why": "Catches notes that slipped through before they age past same-day."
        },
        {
          "detail": "Log the day's same-day note completion rate into the practice's tracking sheet.\n\nRecord: Same-day completion rate logged for the day",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log completion metric"
        },
        {
          "detail": "Note complete and signed",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Note complete and signed"
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "SOAP clinical note completed and signed the same day with required elements — Any clinical encounter ends; nothing is left unsigned when the day closes.",
      "title": "SOAP clinical note completed and signed the same day with required elements",
      "trigger": "Any clinical encounter ends; nothing is left unsigned when the day closes",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "SOAP note content/timing; itemized informed-consent elements; AI-scribe clinician sign-off before charting — generic functional equivalent (standard-of-care/state dental-board recordkeeping practice, not this HIPAA section)",
          "repaired": {
            "action": "generic",
            "evidence": "'A covered entity must retain the documentation required by paragraph (j)(1) of this section for six years from the date of its creation or the date when it last was in effect, whichever is later.' Documentation required by the Privacy Rule (policies/procedures, Privacy Official designation, training records, complaints, sanctions, mitigation) is what §164.530 actually requires retained. Nothing in this text addresses same-day SOAP signing, informed-consent element checklists, or scribe sign-off workflow.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.530 (documentation)",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
            }
          },
          "source": "No federal authority found for the specific content requirements. 45 CFR §164.530 (HIPAA Privacy Rule administrative requirements) mandates a covered entity's OWN 6-year retention of its privacy-compliance paperwork (policies, workforce training, sanctions, complaints) — it does not require same-day-signed SOAP notes, itemized informed-consent elements, or clinician sign-off on an AI-drafted note before it enters the record. These are dental-recordkeeping/standard-of-care matters (state dental board practice-act rules), not cached or verified in this repo — generic functional equivalent"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "source": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "url": "https://www.dbc.ca.gov/formspubs/lawbook_dental.pdf"
        },
        {
          "kind": "generic",
          "label": "Doctrine of informed consent — general elements (diagnosis, nature/purpose, risks, benefits, alternatives, prognosis without treatment) as codified across US state dental practice acts",
          "source": "Doctrine of informed consent — general elements (diagnosis, nature/purpose, risks, benefits, alternatives, prognosis without treatment) as codified across US state dental practice acts"
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "cdoc-002",
      "kind": "operational",
      "materials": [
        "written consent form specific to the procedure",
        "diagnostic images/radiographs to show the patient",
        "cost estimate from the treatment plan"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "patient",
        "caregiver",
        "treatment-coordinator",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm the planned procedure is irreversible, surgical, endodontic, prosthetic, sedation-involving, or otherwise high-risk and therefore requires documented informed consent.\n\nWhy: Not every routine service needs a separate signed consent form.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the procedure requiring consent",
          "why": "Not every routine service needs a separate signed consent form."
        },
        {
          "detail": "Is the patient a minor or otherwise unable to consent for themselves?",
          "forks": [
            {
              "advised": false,
              "goto": "s12",
              "id": "minor",
              "label": "Minor or dependent adult — caregiver/guardian must consent"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "adult",
              "label": "Competent adult patient consents for themselves"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient a minor or otherwise unable to consent for themselves?"
        },
        {
          "detail": "State the diagnosis or working diagnosis in terms the patient/caregiver can understand, using the diagnostic images as visual support.\n\nWhy: Consent requires understanding what condition is being treated, not just what will be done.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the diagnosis in plain language",
          "why": "Consent requires understanding what condition is being treated, not just what will be done."
        },
        {
          "detail": "Describe what the procedure involves, why it is recommended, and the expected outcome.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Explain nature and purpose of the recommended procedure"
        },
        {
          "detail": "List the risks specific to this procedure (e.g., infection, nerve involvement, failure, need for retreatment) in plain language.\n\nWhy: Material risk disclosure is a core legal element of informed consent.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Disclose material risks and possible complications",
          "why": "Material risk disclosure is a core legal element of informed consent."
        },
        {
          "detail": "Describe other treatment options and their tradeoffs, and explicitly describe the expected outcome of doing nothing.\n\nWhy: Consent is not informed unless the patient knows there were other paths, including declining.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Present reasonable alternatives, including no treatment",
          "why": "Consent is not informed unless the patient knows there were other paths, including declining."
        },
        {
          "detail": "Share the fee estimate for the recommended procedure from the treatment plan before the patient signs.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Disclose estimated cost"
        },
        {
          "detail": "Ask the patient/caregiver directly whether they have questions, and document the questions asked and answers given.\n\nWhy: Documented Q&A is evidence the conversation, not just the form, took place.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Invite and answer questions",
          "why": "Documented Q&A is evidence the conversation, not just the form, took place."
        },
        {
          "detail": "The patient (or authorized caregiver) signs the written consent form before the procedure begins; the dentist countersigns.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Signature obtained before proceeding.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "role": "patient",
          "title": "Signature obtained before proceeding"
        },
        {
          "detail": "Scan or attach the signed consent form into the chart and link it to today's SOAP note.\n\nRecord: Signed consent form scanned/attached to the chart, linked to the SOAP note for the visit",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "File the signed consent in the chart"
        },
        {
          "detail": "Informed consent complete; procedure may proceed",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Informed consent complete; procedure may proceed"
        },
        {
          "detail": "Verify the person present has legal authority to consent for the patient (parent, legal guardian, or documented healthcare proxy).\n\nWhy: A signature from someone without authority to consent is not valid consent.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm caregiver/guardian identity and authority",
          "why": "A signature from someone without authority to consent is not valid consent."
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Informed consent — diagnosis, options, risks, alternatives, no-treatment, questions, signature — Before any irreversible, surgical, endodontic, prosthetic, sedation or high-risk procedure.",
      "title": "Informed consent — diagnosis, options, risks, alternatives, no-treatment, questions, signature",
      "trigger": "Before any irreversible, surgical, endodontic, prosthetic, sedation or high-risk procedure",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "source": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "url": "https://www.dbc.ca.gov/formspubs/lawbook_dental.pdf"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §8.3 Refusal of Treatment (in-repo refusal documentation and palliative-care duty)",
          "repaired": {
            "action": "replace",
            "evidence": "### 8.3 Refusal of Treatment\n- Document patient's informed refusal: what was recommended, risks explained, patient understood\n- Patient or guardian signs refusal form\n- Never abandon a patient in acute pain — provide emergency palliative care",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.2 (in-repo refusal documentation)",
              "url": null
            }
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.3"
        },
        {
          "kind": "generic",
          "label": "Informed-refusal doctrine — mirror of informed consent, applied to declined care, as recognized broadly in US health law",
          "source": "Informed-refusal doctrine — mirror of informed consent, applied to declined care, as recognized broadly in US health law"
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "cdoc-003",
      "kind": "operational",
      "materials": [
        "informed refusal form",
        "chart note template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note exactly what was recommended and what the patient is declining.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Patient declines recommended treatment, x-rays, perio therapy or referral"
        },
        {
          "detail": "Restate, in plain language, what could happen if the recommended care is not done (e.g., disease progression, tooth loss, missed diagnosis).\n\nWhy: A refusal is only 'informed' if the risk of refusing was actually communicated.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Re-confirm the patient understands the risks of declining",
          "why": "A refusal is only 'informed' if the risk of refusing was actually communicated."
        },
        {
          "detail": "Is a lesser or palliative alternative appropriate?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "offer",
              "label": "Offer palliative or lesser alternative care"
            },
            {
              "goto": "s5",
              "id": "none",
              "label": "No reasonable alternative to offer"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a lesser or palliative alternative appropriate?"
        },
        {
          "detail": "Even when a patient refuses full treatment, note that a lesser or comfort-focused option was offered and either accepted or also declined.\n\nWhy: A dentist retains a duty to address pain/infection even when a patient declines optimal treatment.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Document the palliative-care duty was met",
          "why": "A dentist retains a duty to address pain/infection even when a patient declines optimal treatment."
        },
        {
          "detail": "The patient signs a written informed refusal form; if the patient declines to sign, document that refusal-to-sign in the chart with a witness.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Signed refusal obtained.",
            "type": "safety"
          },
          "id": "s5",
          "kind": "gate",
          "role": "patient",
          "title": "Signed refusal obtained"
        },
        {
          "detail": "Attach the signed refusal form (or witnessed refusal-to-sign note) to the chart and link it to today's SOAP note.\n\nRecord: Signed refusal form (or witnessed refusal-to-sign note) attached to the chart, linked to the SOAP note",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "File the refusal and set follow-up"
        },
        {
          "detail": "Add a chart flag so the recommendation is revisited at the patient's next hygiene or exam visit rather than dropped silently.\n\nWhy: Circumstances and patient willingness change; the recommendation should not simply disappear from view.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Flag the declined recommendation for the next recall",
          "why": "Circumstances and patient willingness change; the recommendation should not simply disappear from view."
        },
        {
          "detail": "Informed refusal documented",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Informed refusal documented"
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Informed refusal documentation and palliative-care duty — A patient declines recommended treatment, radiographs, periodontal therapy or a referral after the risks are explained.",
      "title": "Informed refusal documentation and palliative-care duty",
      "trigger": "A patient declines recommended treatment, radiographs, periodontal therapy or a referral after the risks are explained",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery — openly published accreditation standard",
          "source": "Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery — openly published accreditation standard",
          "url": "https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/universal-protocol/up_poster1.pdf"
        },
        {
          "kind": "generic",
          "label": "No in-repo or external authority located requiring a formal pre-procedure time-out for routine dental treatment — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No in-repo or external authority located requiring a formal pre-procedure time-out for routine dental treatment — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Read DOCS/TECHNICAL_PROTOCOLS.md §8.1 in full: it is the SOAP clinical-note-format section (Subjective/Objective/Assessment/Plan) and contains no time-out, patient/tooth/procedure verification, or allergy-check content. Searched the rest of the document (§§1-8) for any time-out content; none exists. The Joint Commission Universal Protocol governs accredited hospitals/surgery centers, not routine outpatient dental offices, and I found no dental-specific regulatory citation requiring a formal time-out.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (in-repo time-out)",
              "url": null
            }
          },
          "source": "No in-repo or external authority located requiring a formal pre-procedure time-out for routine dental treatment — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 2,
      "frequency": "per-use",
      "id": "cdoc-004",
      "kind": "operational",
      "materials": [
        "chart open to today's treatment plan",
        "radiograph for the tooth being treated",
        "allergy list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Stop before administering local anesthetic or beginning the procedure; do not proceed until the time-out is complete.\n\nWhy: The time-out must happen at the point of no return, not earlier when details could still change.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Pause immediately before the irreversible step",
          "why": "The time-out must happen at the point of no return, not earlier when details could still change."
        },
        {
          "detail": "Confirm patient name and date of birth against the chart, out loud, with the patient or caregiver.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Verify patient identity"
        },
        {
          "detail": "State the tooth number(s) and planned procedure out loud and compare against the treatment plan and radiograph on screen.\n\nWhy: Wrong-tooth errors are preventable almost entirely by this single verbal check.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Verify tooth number and procedure against the chart and radiograph",
          "why": "Wrong-tooth errors are preventable almost entirely by this single verbal check."
        },
        {
          "detail": "Confirm the appropriate consent form (per cdoc-002) is signed and present in the chart before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Verify signed consent is on file for today's procedure"
        },
        {
          "detail": "State known allergies (especially to anesthetics, latex, or medications) out loud and confirm they are accounted for in today's plan.\n\nWhy: Allergy misses are a leading cause of preventable adverse events in-chair.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Verify allergies and medical alerts",
          "why": "Allergy misses are a leading cause of preventable adverse events in-chair."
        },
        {
          "detail": "The treating dentist verbally confirms all four checks (patient, tooth/procedure, consent, allergies) passed before administering anesthetic or beginning the procedure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms all checks passed before proceeding.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms all checks passed before proceeding"
        },
        {
          "detail": "Note in the chart that the time-out was completed, including any discrepancy found and how it was resolved.\n\nRecord: Time-out completion noted in the chart/SOAP note for the visit, with any discrepancy found and how it was resolved",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Document the time-out was performed"
        },
        {
          "detail": "Time-out complete; procedure may begin",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Time-out complete; procedure may begin"
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Pre-procedure time-out — right patient, tooth, procedure, consent, allergies — Immediately before local anesthetic, an extraction, endodontic access or any irreversible step.",
      "title": "Pre-procedure time-out — right patient, tooth, procedure, consent, allergies",
      "trigger": "Immediately before local anesthetic, an extraction, endodontic access or any irreversible step",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §1683 (record alteration)",
          "source": "CA B&P §1683 (record alteration)",
          "url": "https://www.dbc.ca.gov/formspubs/lawbook_dental.pdf"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.526 (amendment of records)",
          "source": "HIPAA 45 CFR 164.526 (amendment of records)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md contains no section on chart correction, late entry, or amendment-without-alteration; nearest section (§8.1, SOAP note requirements) states only what a note must contain, not how to correct or append to one after the fact — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md contains no section on chart correction, late entry, or amendment-without-alteration; nearest section (§8.1, SOAP note requirements) states only what a note must contain, not how to correct or append to one after the fact — generic functional equivalent (single dated/initialed addendum, never delete or overwrite the original entry)"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Direct read of DOCS/TECHNICAL_PROTOCOLS.md §8 (lines 248-267): §8.1 SOAP format, §8.2 informed consent documentation, §8.3 refusal of treatment. No mention of 'correction', 'late entry', 'addendum', or 'altering the original' anywhere in the file (confirmed by grep).",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.3 (in-repo chart correction)",
              "url": null
            }
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md contains no section on chart correction, late entry, or amendment-without-alteration; nearest section (§8.1, SOAP note requirements) states only what a note must contain, not how to correct or append to one after the fact — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "cdoc-005",
      "kind": "operational",
      "materials": [
        "original signed note",
        "chart correction/addendum template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note what was found: an error in a signed note, a missing element, or a note that was never signed at all.\n\nWhy: Establishes the fact pattern before any edit is made.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Error, omission or unsigned note identified",
          "why": "Establishes the fact pattern before any edit is made."
        },
        {
          "detail": "The original signed note stays intact and legible; corrections are made only as a new, separately timestamped and signed addendum that references the original entry.\n\nWhy: An altered original record undermines the record's legal and clinical trustworthiness and can be read as evidence of concealment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Original entry must never be deleted or overwritten.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Original entry must never be deleted or overwritten",
          "why": "An altered original record undermines the record's legal and clinical trustworthiness and can be read as evidence of concealment."
        },
        {
          "detail": "Is this a correction to an existing signed note, or a late entry for a note never written?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "correction",
              "label": "Correction to an existing signed note"
            },
            {
              "goto": "s8",
              "id": "late",
              "label": "Late entry — note was never written"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this a correction to an existing signed note, or a late entry for a note never written?"
        },
        {
          "detail": "State clearly what is being corrected and why, referencing the date/id of the original note; do not remove or obscure the original text.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Write a dated, signed addendum"
        },
        {
          "detail": "The provider making the correction or late entry signs and dates it before it is filed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Author signs the addendum or late entry.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Author signs the addendum or late entry"
        },
        {
          "detail": "File the new addendum or late-entry note in the chart, linked to the original entry it references.\n\nRecord: New addendum or late-entry note filed and linked to the original entry it references",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "File the addendum/late entry in the chart"
        },
        {
          "detail": "Correction or late entry filed without altering the original",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Correction or late entry filed without altering the original"
        },
        {
          "detail": "Write the note content and explicitly label it 'Late entry' with the current date/time and the date of the original encounter it describes.\n\nWhy: Labeling it late preserves the true timeline instead of implying it was written same-day.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Write the late entry, labeled as late",
          "why": "Labeling it late preserves the true timeline instead of implying it was written same-day."
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Chart correction and late entry without altering the original — An error or omission is found in a signed note, or a note was never signed.",
      "title": "Chart correction and late entry without altering the original",
      "trigger": "An error or omission is found in a signed note, or a note was never signed",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "AB 3030 (Cal. H&S §1339.75) — GenAI-generated patient-facing clinical communications, provider-reviewed exemption",
          "source": "AB 3030 (Cal. H&S §1339.75) — GenAI-generated patient-facing clinical communications, provider-reviewed exemption",
          "url": "https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240AB3030"
        },
        {
          "kind": "regulation",
          "label": "SOAP note content/timing; itemized informed-consent elements; AI-scribe clinician sign-off before charting — generic functional equivalent (standard-of-care/state dental-board recordkeeping practice, not this HIPAA section)",
          "repaired": {
            "action": "generic",
            "evidence": "'A covered entity must retain the documentation required by paragraph (j)(1) of this section for six years from the date of its creation or the date when it last was in effect, whichever is later.' Documentation required by the Privacy Rule (policies/procedures, Privacy Official designation, training records, complaints, sanctions, mitigation) is what §164.530 actually requires retained. Nothing in this text addresses same-day SOAP signing, informed-consent element checklists, or scribe sign-off workflow.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.530 (documentation)",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
            }
          },
          "source": "No federal authority found for the specific content requirements. 45 CFR §164.530 (HIPAA Privacy Rule administrative requirements) mandates a covered entity's OWN 6-year retention of its privacy-compliance paperwork (policies, workforce training, sanctions, complaints) — it does not require same-day-signed SOAP notes, itemized informed-consent elements, or clinician sign-off on an AI-drafted note before it enters the record. These are dental-recordkeeping/standard-of-care matters (state dental board practice-act rules), not cached or verified in this repo — generic functional equivalent"
        },
        {
          "kind": "generic",
          "label": "DOCS/SUITE_HITL_AND_DISCLOSURE.md (in-repo HITL/AI disclosure model)",
          "source": "DOCS/SUITE_HITL_AND_DISCLOSURE.md (in-repo HITL/AI disclosure model)"
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "cdoc-006",
      "kind": "operational",
      "materials": [
        "AI-drafted note/plan/letter output",
        "original encounter recording or source material used to generate the draft"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The voice scribe or AI drafting tool generates a candidate note, treatment-plan summary, or patient letter from the encounter.\n\nWhy: The draft is a starting point, not a finished clinical record.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "AI tool produces a draft note, plan or letter",
          "why": "The draft is a starting point, not a finished clinical record."
        },
        {
          "detail": "The treating clinician reads the entire AI draft against their own memory of the encounter before accepting, editing or rejecting any part of it.\n\nWhy: AI drafts can hallucinate findings or mis-transcribe; the record must reflect what actually happened, not what the model inferred.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Never auto-submit — licensed clinician reviews before anything enters the record.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Never auto-submit — licensed clinician reviews before anything enters the record",
          "why": "AI drafts can hallucinate findings or mis-transcribe; the record must reflect what actually happened, not what the model inferred."
        },
        {
          "detail": "Does the draft need edits?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "edit",
              "label": "Edit inaccurate or incomplete sections"
            },
            {
              "goto": "s5",
              "id": "accept",
              "label": "Draft is accurate as generated"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the draft need edits?"
        },
        {
          "detail": "Edit the draft directly so the final text matches the clinician's own clinical judgment and recollection of the encounter.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Correct the draft"
        },
        {
          "detail": "Will this text reach the patient directly (letter, portal message, after-visit summary)?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "patient-facing",
              "label": "Yes — patient-facing communication"
            },
            {
              "goto": "s7",
              "id": "internal",
              "label": "No — internal chart note only"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Will this text reach the patient directly (letter, portal message, after-visit summary)?"
        },
        {
          "detail": "Any AI-generated content reaching the patient carries a disclosure such as 'AI-generated — reviewed by a licensed provider' per AB 3030's provider-reviewed exemption pattern.\n\nWhy: AB 3030 attaches to GenAI-generated patient-facing clinical communications; the provider-reviewed disclosure is what keeps this compliant.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Add the AI-disclosure statement",
          "why": "AB 3030 attaches to GenAI-generated patient-facing clinical communications; the provider-reviewed disclosure is what keeps this compliant."
        },
        {
          "detail": "Sign and file the final reviewed text in the chart, keeping the original AI draft on hand as a source reference.\n\nRecord: Final reviewed and signed note/plan/letter filed in the chart, with the original AI draft retained as a source reference",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Sign off the final, reviewed text"
        },
        {
          "detail": "AI-assisted content reviewed, edited as needed and signed",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "AI-assisted content reviewed, edited as needed and signed"
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "AI-assisted scribe or drafted note, plan or letter — clinician review, edit and sign-off before it enters the record — A voice scribe or AI tool drafts clinical text; patient-facing output additionally follows the AI-disclosure class.",
      "title": "AI-assisted scribe or drafted note, plan or letter — clinician review, edit and sign-off before it enters the record",
      "trigger": "A voice scribe or AI tool drafts clinical text; patient-facing output additionally follows the AI-disclosure class",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "source": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "url": "https://www.dbc.ca.gov/formspubs/lawbook_dental.pdf"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (in-repo treatment plan documentation)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (in-repo treatment plan documentation)"
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 12,
      "frequency": "per-use",
      "id": "cdoc-007",
      "kind": "operational",
      "materials": [
        "written treatment plan template",
        "fee schedule / cost estimate",
        "insurance benefit estimate if applicable"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Translate the diagnosis and recommended procedures into a written, itemized treatment plan.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Treatment plan prepared from diagnosis"
        },
        {
          "detail": "Provide a written estimate for each procedure in the plan, including any known insurance estimate, before the patient decides.\n\nWhy: Cost surprises after the fact are a leading source of billing disputes and patient distrust.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Disclose fees for each item",
          "why": "Cost surprises after the fact are a leading source of billing disputes and patient distrust."
        },
        {
          "detail": "Walk the patient through the sequence, purpose and cost of each item; note that clinical risks/alternatives are covered separately under informed consent (cdoc-002) for irreversible items.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the plan to the patient"
        },
        {
          "detail": "Does the patient accept, partially accept, or defer the plan?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accept",
              "label": "Accept the plan as presented"
            },
            {
              "goto": "s8",
              "id": "partial",
              "label": "Accept part of the plan"
            },
            {
              "goto": "s9",
              "id": "defer",
              "label": "Defer the decision"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient accept, partially accept, or defer the plan?"
        },
        {
          "detail": "Provide a written or electronic copy of the treatment plan and fee estimate to the patient before they leave, or via the patient portal the same day.\n\nWhy: Patients need their own copy to review cost and sequence at home, and it is the documentary record of what was disclosed.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Give the patient a copy of the plan",
          "why": "Patients need their own copy to review cost and sequence at home, and it is the documentary record of what was disclosed."
        },
        {
          "detail": "File the signed and dated treatment plan with its fee disclosure into the chart.\n\nRecord: Signed/dated treatment plan with fee disclosure filed in the chart",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "File the plan in the chart"
        },
        {
          "detail": "Treatment plan documented and patient copy provided",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Treatment plan documented and patient copy provided"
        },
        {
          "detail": "Mark each plan item individually as accepted or deferred in the chart.\n\nRecord: Accepted vs. deferred items noted individually in the chart",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document which items were accepted"
        },
        {
          "detail": "Note the deferral in the chart and set a follow-up flag for the next recall or callback.\n\nRecord: Deferral noted with a follow-up flag for next recall or callback",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the deferral and follow-up plan"
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Treatment plan documentation, fee disclosure and patient copy — A plan is presented and accepted or deferred.",
      "title": "Treatment plan documentation, fee disclosure and patient copy",
      "trigger": "A plan is presented and accepted or deferred",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "label": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "source": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
          "url": "https://www.dbc.ca.gov/formspubs/lawbook_dental.pdf"
        },
        {
          "label": "For adverse-event disclosure practice (stabilize, document, disclose, report, follow up) as broadly taught in US patient-safety programs — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for adverse-event disclosure practice (stabilize, document, disclose, report, follow up) as broadly taught in US patient-safety programs"
          },
          "source": "For adverse-event disclosure practice (stabilize, document, disclose, report, follow up) as broadly taught in US patient-safety programs — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "cdoc-008",
      "kind": "operational",
      "materials": [
        "adverse event / near-miss report form",
        "incident timeline notes",
        "malpractice carrier contact information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If there is any sign of a life-threatening condition (airway compromise, severe allergic reaction, uncontrolled bleeding, loss of consciousness), call 911/EMS and begin stabilizing the patient simultaneously — one team member calls while another stabilizes; do not delay either action for documentation.\n\nWhy: Patient safety always precedes documentation; the record can wait, the airway cannot.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Is the patient in immediate medical danger?.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Is the patient in immediate medical danger?",
          "why": "Patient safety always precedes documentation; the record can wait, the airway cannot."
        },
        {
          "detail": "Was EMS activated?",
          "forks": [
            {
              "advised": false,
              "goto": "s3",
              "id": "ems-called",
              "label": "Yes — EMS called and patient stabilized/transported"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "no-ems",
              "label": "No — incident did not require EMS"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Was EMS activated?"
        },
        {
          "detail": "The treating dentist notifies the office manager and practice owner of the incident or near-miss as soon as the patient is stable, before the end of the day.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Notify office manager and practice owner immediately"
        },
        {
          "detail": "Write down what occurred, when, who was present, and what actions were taken — facts only, no speculation about fault.\n\nWhy: A factual contemporaneous record is more reliable and more defensible than a reconstructed one written later.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Document a factual timeline of what happened",
          "why": "A factual contemporaneous record is more reliable and more defensible than a reconstructed one written later."
        },
        {
          "detail": "The treating dentist personally and promptly discloses what happened to the patient (or caregiver), what is being done about it, and next steps — this is not delegated to front desk staff.\n\nWhy: Prompt, honest disclosure is both an ethical obligation and reduces the likelihood of the incident being perceived as concealed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the incident to the patient before ending the visit.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Disclose the incident to the patient before ending the visit",
          "why": "Prompt, honest disclosure is both an ethical obligation and reduces the likelihood of the incident being perceived as concealed."
        },
        {
          "detail": "The compliance officer (generic functional equivalent role) reviews the incident report for completeness and determines whether the malpractice carrier or any regulatory body must be notified.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews the report and reporting obligations.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews the report and reporting obligations"
        },
        {
          "detail": "Does this incident meet the threshold for malpractice carrier notification?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "notify",
              "label": "Notify the malpractice carrier"
            },
            {
              "goto": "s9",
              "id": "internal-only",
              "label": "Internal report only, threshold not met"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does this incident meet the threshold for malpractice carrier notification?"
        },
        {
          "detail": "Send the incident report to the malpractice carrier per their reporting process and log the notification date.\n\nRecord: Malpractice carrier notified with the incident report attached",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "File carrier notification"
        },
        {
          "detail": "File the final report and link it to the patient's chart entry and the disclosure conversation note.\n\nRecord: Final adverse event or near-miss report filed, linked to the patient's chart entry and the disclosure conversation note",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the complete incident/near-miss report"
        },
        {
          "detail": "Within 5 business days of the incident, review it with relevant staff to identify process changes (e.g., reinforcing the time-out protocol) that reduce recurrence.\n\nWhy: A near-miss or event that is not turned into a process improvement is likely to recur.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Schedule a follow-up review to identify prevention steps",
          "why": "A near-miss or event that is not turned into a process improvement is likely to recur."
        },
        {
          "detail": "Incident documented, disclosed and reviewed",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Incident documented, disclosed and reviewed"
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Clinical adverse event or near-miss report and disclosure to the patient — Wrong tooth, wrong procedure, aspiration, injury or another clinical incident occurs or is nearly missed.",
      "title": "Clinical adverse event or near-miss report and disclosure to the patient",
      "trigger": "Wrong tooth, wrong procedure, aspiration, injury or another clinical incident occurs or is nearly missed",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.530 (documentation) and 164.524/164.526 (patient access/amendment) — photographs in the chart are part of the designated record set",
          "source": "HIPAA 45 CFR 164.530 (documentation) and 164.524/164.526 (patient access/amendment) — photographs in the chart are part of the designated record set",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "statute",
          "label": "No specific authority located governing clinical-photograph attachment/consent-on-file for dental patient records — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No specific authority located governing clinical-photograph attachment/consent-on-file for dental patient records — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched CA B&P §1680 (unprofessional-conduct/license-suspension article, not a records-content provision) and 16 CCR §1051 (confirmed by audit to be the Dental Board's advertising-discount-disclosure regulation). Searched further for a CA dental-record-content provision reaching clinical photographs specifically (B&P §1684.1 governs record production-to-the-Board timelines and confidentiality generally, not photograph/consent-attachment content) and found no provision I could read in full text that names photographs-with-consent as a required record element. Rather than cite §1684.1 on a paraphrase, no authority is claimed.",
            "ticket": "PROT-017",
            "was": {
              "source": "CA B&P §1680 / 16 CCR §1051 patient record requirements",
              "url": null
            }
          },
          "source": "No specific authority located governing clinical-photograph attachment/consent-on-file for dental patient records — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": ": consistent view set, filename/date convention and consent gate before capture — not tied to any camera or imaging vendor — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: consistent view set, filename/date convention and consent gate before capture — not tied to any camera or imaging vendor"
          },
          "source": ": consistent view set, filename/date convention and consent gate before capture — not tied to any camera or imaging vendor — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "cdoc-009",
      "kind": "operational",
      "materials": [
        "intraoral/extraoral camera or camera-enabled device",
        "consent form or e-consent module",
        "standardized view checklist",
        "practice management system record"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note why photos are indicated for this case: baseline record, treatment progress, cosmetic case documentation, insurance/claim support, or referral documentation.\n\nWhy: A stated clinical reason keeps photography purposeful and gives the chart a reviewable rationale rather than an unexplained image file.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the clinical reason photographs are needed",
          "why": "A stated clinical reason keeps photography purposeful and gives the chart a reviewable rationale rather than an unexplained image file."
        },
        {
          "detail": "Confirm a signed or e-signed consent for clinical photography and its intended use (chart, referral, case presentation, insurance) is on file before any image is taken. If none exists, obtain it now and do not proceed without it.\n\nWhy: Photographs are PHI once linked to a patient; capturing without consent on file is a documentation and privacy failure, not just a courtesy.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent for clinical photography on file before capture.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "assistant",
          "title": "Consent for clinical photography on file before capture",
          "why": "Photographs are PHI once linked to a patient; capturing without consent on file is a documentation and privacy failure, not just a courtesy."
        },
        {
          "detail": "Verify the patient's name and date of birth against the chart open in the practice management system before capture begins.\n\nWhy: Capturing into the wrong open chart is the single largest cause of misfiled clinical images (see cdoc-010).",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm patient identity matches the chart to be opened",
          "why": "Capturing into the wrong open chart is the single largest cause of misfiled clinical images (see cdoc-010)."
        },
        {
          "detail": "Capture the practice's standard view set in order (e.g. full-face relaxed, full-face smiling, profile, retracted frontal, right and left buccal, upper and lower occlusal, and any tooth-specific or procedure-specific views the case calls for). Confirm framing, lighting and focus on each before moving to the next.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "intraoral/extraoral camera or camera-enabled device",
            "standardized view checklist"
          ],
          "role": "assistant",
          "title": "Capture the standardized view set"
        },
        {
          "detail": "Review the captured set immediately, before the patient leaves the chair.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "usable",
              "label": "All views usable"
            },
            {
              "goto": "s11",
              "id": "retake",
              "label": "One or more views unusable"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Are all required views usable (in focus, correctly framed, diagnostic quality)?"
        },
        {
          "detail": "Apply the patient's chart identifier, the date, and the view labels to each image per the practice's filing convention before transfer off the capture device.\n\nWhy: Unlabeled images are the second most common cause of misfiling and delay chart review.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Label and date the image set per the practice's naming convention",
          "why": "Unlabeled images are the second most common cause of misfiling and delay chart review."
        },
        {
          "detail": "Transfer and attach the labeled images to the correct patient's record in the practice management system, then delete the working copy from the capture device per the practice's device-clearing policy.\n\nRecord: Clinical photographs (labeled, dated) filed under the patient's chart in the practice management system; capture device cleared.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "File the labeled image set into the patient's chart"
        },
        {
          "detail": "Confirm the filed set supports the stated clinical reason (baseline, progress, referral, insurance) and is complete; note any finding the images inform in the clinical note.\n\nWhy: Photographs support but do not replace a written clinical note — the dentist's review ties the image set back to the chart narrative.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews the filed images against the clinical indication",
          "why": "Photographs support but do not replace a written clinical note — the dentist's review ties the image set back to the chart narrative."
        },
        {
          "detail": "Record completion status (full view set / retake needed / consent gap) in the practice's documentation-quality log, generic front-office record-keeping.\n\nWhy: A simple log is how the practice catches drift (e.g. rising retake rates or consent gaps) before it becomes a pattern.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Office manager logs the session for the monthly documentation-quality review",
          "why": "A simple log is how the practice catches drift (e.g. rising retake rates or consent gaps) before it becomes a pattern."
        },
        {
          "detail": "Clinical photograph set consented, captured, filed and reviewed",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Clinical photograph set consented, captured, filed and reviewed"
        },
        {
          "detail": "Recapture only the specific views that failed the quality check, using the same standardized positioning.\n\nWhy: A retake now avoids an incomplete record and a second patient visit for photography alone.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Retake the unusable views",
          "why": "A retake now avoids an incomplete record and a second patient visit for photography alone."
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Clinical photographs and images attached to the record with consent on file — A case needs photographic documentation in the chart.",
      "title": "Clinical photographs and images attached to the record with consent on file",
      "trigger": "A case needs photographic documentation in the chart",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.526 (amendment of PHI) and 164.530 (documentation, safeguards)",
          "source": "HIPAA 45 CFR 164.526 (amendment of PHI) and 164.530 (documentation, safeguards)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Breach Notification Rule, 45 CFR 164.400-414 — four-factor risk-of-compromise assessment (164.402) and ≤60-day notification requirement (164.404)",
          "source": "HIPAA Breach Notification Rule, 45 CFR 164.400-414 — four-factor risk-of-compromise assessment (164.402) and ≤60-day notification requirement (164.404)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html"
        },
        {
          "kind": "statute",
          "label": "— chart-correction procedure, no single citable numbered provision confirmed — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic functional equivalent — chart-correction procedure, no single citable numbered provision confirmed"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CA B&P §1683(a) requires that every dentist or dental health professional who performs a service identify themselves in the record by signing or initialing next to the service and date it — it says nothing about correcting or altering an existing entry. Separately, Dental Board of California guidance states: 'information may not be removed from a patient's record under any circumstance. Corrections can be done using single-line strikeouts, and the date the correction was made should be noted... altering a patient's record with intent to deceive is unprofessional conduct' — but this is discussed as general Board/CDA practice guidance, not tied to one numbered statute or regulation section in the sources found.",
            "ticket": "PROT-017",
            "was": {
              "source": "CA B&P §1683 (record alteration) — corrections must be traceable, never delete the original entry",
              "url": null
            }
          },
          "source": "— chart-correction procedure, no single citable numbered provision confirmed — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": ": misfiled-entry containment, correction and duplicate-merge workflow — not tied to any practice management system vendor — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: misfiled-entry containment, correction and duplicate-merge workflow — not tied to any practice management system vendor"
          },
          "source": ": misfiled-entry containment, correction and duplicate-merge workflow — not tied to any practice management system vendor — Practice policy — no published authority governs this step."
        }
      ],
      "class": "clinical-documentation-consent",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "cdoc-010",
      "kind": "operational",
      "materials": [
        "practice management system audit/change log",
        "chart-correction log",
        "incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "compliance-officer",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pause additional charting on both the chart where the entry was found and the chart it should belong to. Write down exactly what was found, when, and by whom, before touching either record.\n\nWhy: Acting on a suspected misfile before recording what was actually seen risks losing the evidence needed to fix it correctly and to assess who else may have seen the wrong-patient data.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Stop further entries into the affected chart(s) and note what was found",
          "why": "Acting on a suspected misfile before recording what was actually seen risks losing the evidence needed to fix it correctly and to assess who else may have seen the wrong-patient data."
        },
        {
          "detail": "Record which fact pattern this is — a single entry, radiograph or photo filed in the wrong chart, or two separate charts existing for one patient — since the remedy differs (copy-into-correct-chart vs. chart merge) and this classification is what the compliance officer signs off on before technical_correction.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Classify the scope: single misfiled entry/image, or two full duplicate charts for the same patient"
        },
        {
          "detail": "Office manager reports the finding to the compliance officer with the note from contain_access and the classification from classify_issue.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Office manager hands the finding to the compliance officer"
        },
        {
          "detail": "Compliance officer reviews the finding and approves the specific correction (move the entry, or merge the duplicate charts) before any technical change is made. No entry is deleted at this or any later step — corrections are additive per §1683.\n\nWhy: Moving or merging clinical records without a named sign-off risks silently destroying the audit trail HIPAA and state record-keeping rules require.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer signs off on the correction plan before any record is moved or merged.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer signs off on the correction plan before any record is moved or merged",
          "why": "Moving or merging clinical records without a named sign-off risks silently destroying the audit trail HIPAA and state record-keeping rules require."
        },
        {
          "detail": "For a misfile: copy (not delete) the entry/image into the correct chart with a note explaining the correction, and mark the original location with a visible correction annotation rather than removing it. For a duplicate: merge the two charts using the system's merge function, preserving both charts' full history and the merge audit trail.\n\nWhy: The original entry stays visible with an annotation so any later reviewer can see exactly what moved and why, satisfying the traceable-correction requirement.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Perform the approved correction in the practice management system",
          "why": "The original entry stays visible with an annotation so any later reviewer can see exactly what moved and why, satisfying the traceable-correction requirement."
        },
        {
          "detail": "Dentist reviews the corrected chart and the chart the entry was removed from (or the merged chart) to confirm the clinical record is now accurate and nothing was lost.\n\nWhy: The person clinically responsible for the chart, not just the person who fixed the filing, confirms the record is right before it's considered closed.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist verifies both charts are clean and complete after correction",
          "why": "The person clinically responsible for the chart, not just the person who fixed the filing, confirms the record is right before it's considered closed."
        },
        {
          "detail": "Assess whether another patient's information was disclosed to the wrong chart's viewers, or whether the affected patient would want to know their record was corrected, per the practice's notification policy.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-notify",
              "label": "No cross-patient disclosure occurred; internal correction only"
            },
            {
              "goto": "s11",
              "id": "notify",
              "label": "Cross-patient disclosure occurred or notification policy requires it"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the affected patient need to be notified?"
        },
        {
          "detail": "Record what was found, the classification, the approved correction, who performed it, verification outcome, and any notification made, in the chart-correction/incident log.\n\nRecord: Incident report entry: discovery, classification, correction taken, verifier, notification outcome — logged in the practice's chart-correction log.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident, correction and outcome"
        },
        {
          "detail": "Identify the contributing cause (e.g. chart not confirmed before capture, duplicate registration at intake) and note one concrete prevention step for the relevant workflow (e.g. reinforcing the identity check in cdoc-009).\n\nWhy: Logging the incident without asking why it happened lets the same misfile recur with the next patient.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Review why the misfile or duplicate occurred and note a prevention step",
          "why": "Logging the incident without asking why it happened lets the same misfile recur with the next patient."
        },
        {
          "detail": "Misfiled entry corrected or duplicate charts merged, verified, and logged",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Misfiled entry corrected or duplicate charts merged, verified, and logged"
        },
        {
          "detail": "Compliance officer confirms notification content and recipients, and runs the HIPAA four-factor risk-of-compromise assessment (nature/extent of PHI, who accessed or viewed it, whether it was actually acquired or viewed, and the extent the risk was mitigated) to determine whether this cross-patient disclosure meets the breach-notification threshold, before contact is made; a qualifying breach must be notified within 60 days of discovery.\n\nWhy: Notification language and thresholds carry regulatory consequences; nothing goes to a patient without a named compliance review first.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on notification before any patient is contacted.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on notification before any patient is contacted",
          "why": "Notification language and thresholds carry regulatory consequences; nothing goes to a patient without a named compliance review first."
        }
      ],
      "subclass": "clinical-documentation-consent-and-records",
      "summary": "Entry, radiograph or photo filed in the wrong patient chart, or duplicate records merge — A note or image is discovered in another patient's chart, or two charts for one patient are found.",
      "title": "Entry, radiograph or photo filed in the wrong patient chart, or duplicate records merge",
      "trigger": "A note or image is discovered in another patient's chart, or two charts for one patient are found",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Daily schedule huddle prep — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Daily schedule huddle prep — generic functional equivalent"
          },
          "source": "Daily schedule huddle prep — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "daily",
      "id": "cenp-001",
      "kind": "clinical",
      "materials": [
        "day sheet / schedule printout or screen",
        "chart access",
        "medical-alert flag list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Open the day sheet for every operatory and provider column; note total patient count and any gaps.\n\nWhy: A gap or overbooked block found now can be fixed before the first patient arrives instead of mid-morning.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Pull the full day's schedule",
          "why": "A gap or overbooked block found now can be fixed before the first patient arrives instead of mid-morning."
        },
        {
          "detail": "Mark each new patient or comprehensive-exam slot; confirm intake forms and any outside records have arrived (cross-reference cenp-002).\n\nWhy: New patients need longer chair time and complete records before the exam starts.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Scan for new-patient and comprehensive-exam appointments",
          "why": "New patients need longer chair time and complete records before the exam starts."
        },
        {
          "detail": "For each patient: allergy flags, anticoagulant or bisphosphonate use, cardiac history, pregnancy, premedication needs, and any note added since the last visit.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check medical-alert flags for every patient on the day"
        },
        {
          "detail": "Flag multi-visit treatment, medically complex patients, anxious patients, and any case carried over from a prior incomplete visit.\n\nWhy: Complex cases scheduled in a standard slot are the most common cause of running behind (see cenp-016).",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Identify complex or high-risk cases needing extra chair time",
          "why": "Complex cases scheduled in a standard slot are the most common cause of running behind (see cenp-016)."
        },
        {
          "detail": "Check the lab tracking log for crowns, dentures, appliances, or night guards due for today's seat/deliver appointments.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm lab cases due back today have arrived"
        },
        {
          "detail": "List the day's complex cases, medical alerts, lab-case status, and any schedule change needed, in the order they will be raised in the huddle.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Write huddle talking points"
        },
        {
          "detail": "Document: Date/time of review and count of flagged items, in the daily operations log (structural only — no patient data written to any non-chart system).\n\nRecord: Date/time of review and count of flagged items, in the daily operations log (structural only — no patient data written to any non-chart system).",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Log that the morning review was completed"
        },
        {
          "detail": "Ready for huddle",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Ready for huddle"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Provider's morning schedule review (complex cases, medical alerts, huddle prep) — Before the morning huddle every clinical day.",
      "title": "Provider's morning schedule review (complex cases, medical alerts, huddle prep)",
      "trigger": "Before the morning huddle every clinical day",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "open_standard",
          "label": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "source": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "cenp-002",
      "kind": "clinical",
      "materials": [
        "intake/health-history forms",
        "records-release log",
        "chart access",
        "outside radiograph viewer"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Export or print the next day's schedule filtered to new patients and any returning patient flagged for a comprehensive re-evaluation.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Pull tomorrow's new and returning patient list"
        },
        {
          "detail": "Are intake / health-history forms complete for each patient?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "complete",
              "label": "Forms complete"
            },
            {
              "goto": "s8",
              "id": "missing",
              "label": "Forms missing or incomplete"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Are intake / health-history forms complete for each patient?"
        },
        {
          "detail": "Are outside records or prior radiographs expected for this patient?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "none-expected",
              "label": "No outside records expected"
            },
            {
              "goto": "s9",
              "id": "expected",
              "label": "Outside records requested but not yet received"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Are outside records or prior radiographs expected for this patient?"
        },
        {
          "detail": "Open the chart, attach any received outside records/radiographs, and flag anything still outstanding at the top of the chart note.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Pull the chart and stage it for the provider"
        },
        {
          "detail": "Read the completed health history, prior treatment notes, and any outside radiographs; note questions to ask the patient at check-in.\n\nWhy: Reviewing records before the patient is seated shortens chair time and catches medical-alert items early.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Review the staged chart before the visit",
          "why": "Reviewing records before the patient is seated shortens chair time and catches medical-alert items early."
        },
        {
          "detail": "Document: Which records were present, which were missing, and any follow-up still pending, noted in the chart's records-status field.\n\nRecord: Which records were present, which were missing, and any follow-up still pending, noted in the chart's records-status field.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Log records status in the chart"
        },
        {
          "detail": "Chart ready for the visit",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Chart ready for the visit"
        },
        {
          "detail": "Send the portal link or call the patient to complete health history before arrival; note the callback in the schedule note.\n\nWhy: Health history must be reviewed before any treatment (see cenp-003); collecting it the day before avoids delaying the chair.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Send or call to request missing intake forms",
          "why": "Health history must be reviewed before any treatment (see cenp-003); collecting it the day before avoids delaying the chair."
        },
        {
          "detail": "Check the records-release log for the request date; re-fax or re-call the sending office if the response window has passed.\n\nRecord: Follow-up attempt logged in the records-release tracking log.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Follow up on the outstanding records request"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Pre-visit chart, records and prior-radiograph review — A new or returning patient is on tomorrow's schedule and intake forms, prior records or outside radiographs have arrived (or are missing).",
      "title": "Pre-visit chart, records and prior-radiograph review",
      "trigger": "A new or returning patient is on tomorrow's schedule and intake forms, prior records or outside radiographs have arrived (or are missing)",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ASA Physical Status Classification (open)",
          "source": "ASA Physical Status Classification (open)"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "cenp-003",
      "kind": "clinical",
      "materials": [
        "health-history form",
        "blood pressure cuff",
        "pulse oximeter (optional)",
        "ASA classification reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the date of the last health-history update; if it is over 12 months old, or the patient states a change at check-in, an update is required today.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm whether the health history needs an update"
        },
        {
          "detail": "Have the patient review and sign the current health-history form, noting any new diagnoses, medications, allergies, or hospitalizations since the last visit.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Collect the updated health history from the patient"
        },
        {
          "detail": "Blood pressure, pulse, and (per practice policy) pulse oximetry and temperature; repeat blood pressure once if the first reading is elevated.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Take and record vital signs"
        },
        {
          "detail": "Are vitals and history within the range for today's planned treatment?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "within-range",
              "label": "Vitals and history within range — proceed"
            },
            {
              "goto": "s9",
              "id": "out-of-range",
              "label": "Vitals elevated or history flags a concern"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Are vitals and history within the range for today's planned treatment?"
        },
        {
          "detail": "Record ASA I–IV based on the updated history and vitals; ASA III or IV triggers additional precautions per practice protocol.\n\nWhy: The ASA class sets the safety baseline for anesthesia, sedation, and appointment length decisions later in the visit.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Assign the ASA Physical Status classification",
          "why": "The ASA class sets the safety baseline for anesthesia, sedation, and appointment length decisions later in the visit."
        },
        {
          "detail": "Check the ASA classification just assigned against the ASA III/IV threshold before proceeding to record the visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "asa-i-ii",
              "label": "ASA I or II — no additional precautions"
            },
            {
              "goto": "s10",
              "id": "asa-iii-iv",
              "label": "ASA III or IV — additional precautions required"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the assigned ASA class require additional precautions?"
        },
        {
          "detail": "Document: Vitals, health-history changes, and ASA classification entered into the patient's chart before any treatment begins.\n\nRecord: Vitals, health-history changes, and ASA classification entered into the patient's chart before any treatment begins.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Record vitals, history update and ASA class in the chart"
        },
        {
          "detail": "Cleared for planned treatment",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Cleared for planned treatment"
        },
        {
          "detail": "The treating dentist reviews the out-of-range finding and personally decides whether to proceed with modification, defer treatment, or refer for medical clearance. No treatment starts on an out-of-range reading without this sign-off.\n\nWhy: An elevated vital or a new medical flag can change what is safe to do that day; this decision cannot be delegated to non-licensed staff.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off required before proceeding or deferring.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off required before proceeding or deferring",
          "why": "An elevated vital or a new medical flag can change what is safe to do that day; this decision cannot be delegated to non-licensed staff."
        },
        {
          "detail": "Confirm medical clearance status, consider a shortened appointment, have the emergency kit and vitals monitoring in place, and consult the patient's physician of record if the classification is new or has changed since the last visit.\n\nWhy: An ASA III or IV classification changes what is safe to do today; the precautions must be in place before treatment, not noted after.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Apply ASA III/IV precautions before proceeding",
          "why": "An ASA III or IV classification changes what is safe to do today; the precautions must be in place before treatment, not noted after."
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Medical history review, vitals and ASA classification before any treatment — A patient is seated for any appointment and the health history is new, more than 12 months old, or the patient reports a change.",
      "title": "Medical history review, vitals and ASA classification before any treatment",
      "trigger": "A patient is seated for any appointment and the health history is new, more than 12 months old, or the patient reports a change",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 World Workshop periodontal classification (staging/grading)",
          "source": "AAP 2017 World Workshop periodontal classification (staging/grading)",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "open_standard",
          "label": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "source": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "cenp-004",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "explorer and mirror",
        "intraoral camera (optional)",
        "radiographs",
        "perio charting form or software",
        "occlusion/TMJ exam checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the pre-visit records review (cenp-002) and medical history/vitals (cenp-003) are already complete for this patient.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review chart, history and radiographs before starting the exam"
        },
        {
          "detail": "Palpate lymph nodes, TMJ, and muscles of mastication; observe facial symmetry and skin.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Extraoral examination"
        },
        {
          "detail": "Lips, buccal mucosa, tongue (all surfaces), floor of mouth, hard and soft palate, oropharynx, gingiva — systematic visual and tactile exam (see cenp-005 for the cancer-screening detail).",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Intraoral soft-tissue examination"
        },
        {
          "detail": "Tooth-by-tooth charting of existing restorations, caries, fractures, and wear, cross-referenced against current radiographs.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Hard-tissue examination"
        },
        {
          "detail": "Probing depths, bleeding on probing, recession, furcation involvement and mobility at mesiobuccal, mid-buccal, distobuccal, mesiolingual, mid-lingual and distolingual sites.\n\nWhy: Six-point charting is the minimum data set needed to stage and grade periodontal disease accurately.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Full periodontal charting, 6 points per tooth",
          "why": "Six-point charting is the minimum data set needed to stage and grade periodontal disease accurately."
        },
        {
          "detail": "Check bite classification, occlusal interferences, wear facets, TMJ sounds and range of motion, and note any parafunctional habit signs.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Occlusion and TMJ evaluation"
        },
        {
          "detail": "Enter findings into the chart in real time using standard charting terminology, confirming tooth numbers and surfaces with the dentist.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Document findings as the dentist calls them out"
        },
        {
          "detail": "The treating dentist personally confirms the diagnosis and staging/grading before any finding moves into a treatment plan or is shared with the patient.\n\nWhy: Diagnosis is a licensed clinical judgment; it cannot be finalized from charted findings alone without the dentist's direct review.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on diagnosis before it enters the treatment plan.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on diagnosis before it enters the treatment plan",
          "why": "Diagnosis is a licensed clinical judgment; it cannot be finalized from charted findings alone without the dentist's direct review."
        },
        {
          "detail": "Document: Complete hard/soft tissue, perio, occlusion and TMJ findings plus the dentist's diagnosis, entered in the chart with date and provider signature.\n\nRecord: Complete hard/soft tissue, perio, occlusion and TMJ findings plus the dentist's diagnosis, entered in the chart with date and provider signature.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Finalize and record the diagnosis"
        },
        {
          "detail": "Exam complete, diagnosis recorded, ready for treatment planning",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Exam complete, diagnosis recorded, ready for treatment planning"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Comprehensive oral examination — adult (hard tissue, soft tissue, perio, occlusion, TMJ) — A new adult patient, or an established patient due for a full re-evaluation after three or more years.",
      "title": "Comprehensive oral examination — adult (hard tissue, soft tissue, perio, occlusion, TMJ)",
      "trigger": "A new adult patient, or an established patient due for a full re-evaluation after three or more years",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "USPSTF oral cancer screening statement (public domain)",
          "source": "USPSTF oral cancer screening statement (public domain)"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "cenp-005",
      "kind": "clinical",
      "materials": [
        "good light source",
        "gauze for tongue retraction",
        "intraoral camera (optional)",
        "referral form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Visually and manually examine lips, buccal mucosa, tongue (lateral and ventral surfaces), floor of mouth, hard/soft palate, oropharynx, and palpate neck and submandibular lymph nodes.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Perform the systematic head, neck and oral screen"
        },
        {
          "detail": "Is any lesion or abnormality found?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-finding",
              "label": "No abnormal finding"
            },
            {
              "goto": "s5",
              "id": "finding",
              "label": "Lesion or abnormality found"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is any lesion or abnormality found?"
        },
        {
          "detail": "Document: Screening performed, no abnormal findings, dated and signed in the chart.\n\nRecord: Screening performed, no abnormal findings, dated and signed in the chart.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Record a normal screening result"
        },
        {
          "detail": "Screening complete, no findings",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Screening complete, no findings"
        },
        {
          "detail": "Check for a clear irritant such as cheek/tongue biting, a sharp restoration edge, or a denture sore spot that would explain the lesion.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Assess whether the lesion has an obvious local cause"
        },
        {
          "detail": "Record whether an obvious local cause was identified and corrected today, or whether no obvious cause was found; the two-week re-check is scheduled next either way.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Note whether the lesion has an obvious, correctable cause"
        },
        {
          "detail": "Book a follow-up appointment in two weeks to re-examine the lesion, whether or not a likely cause was corrected today.\n\nWhy: The two-week interval is the standard window used to see whether a lesion resolves after the irritant is removed, before deciding a biopsy referral is needed.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Schedule the two-week re-check",
          "why": "The two-week interval is the standard window used to see whether a lesion resolves after the irritant is removed, before deciding a biopsy referral is needed."
        },
        {
          "detail": "With existing photography consent, capture a dated photo with a size reference for comparison at the recheck visit.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Photograph and measure the lesion if consent is on file"
        },
        {
          "detail": "Hold the case open until the two-week follow-up appointment occurs; the patient is contacted if they do not return for it.",
          "id": "s9",
          "kind": "timer",
          "role": "hygienist",
          "timer_seconds": 1209600,
          "title": "Wait for the two-week recheck"
        },
        {
          "detail": "At recheck: has the lesion resolved?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "resolved",
              "label": "Lesion resolved"
            },
            {
              "goto": "s13",
              "id": "not-resolved",
              "label": "Lesion persists or has changed"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "At recheck: has the lesion resolved?"
        },
        {
          "detail": "Document: Lesion resolution confirmed at recheck, dated and signed in the chart.\n\nRecord: Lesion resolution confirmed at recheck, dated and signed in the chart.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Record resolution"
        },
        {
          "detail": "Lesion resolved, no referral needed",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Lesion resolved, no referral needed"
        },
        {
          "detail": "The treating dentist personally confirms the persistent-lesion finding and authorizes the specialist referral before it is sent.\n\nWhy: A referral decision for a possible malignancy is a licensed clinical judgment that must not be delegated or auto-generated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off to refer for biopsy/specialist evaluation.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off to refer for biopsy/specialist evaluation",
          "why": "A referral decision for a possible malignancy is a licensed clinical judgment that must not be delegated or auto-generated."
        },
        {
          "detail": "Transmit the referral letter, lesion description, and photo (with minimum-necessary PHI) to the receiving specialist office; confirm receipt.",
          "id": "s14",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Send the referral to oral pathology / oral surgery"
        },
        {
          "detail": "Document: Referral sent, receiving office, date, and lesion description entered in the chart with a tickler to confirm the patient was seen.\n\nRecord: Referral sent, receiving office, date, and lesion description entered in the chart with a tickler to confirm the patient was seen.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Record the referral in the chart"
        },
        {
          "detail": "Referred for specialist evaluation",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Referred for specialist evaluation"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Head, neck and oral cancer screening with the two-week lesion re-check rule — Every comprehensive or periodic exam; a soft-tissue lesion is found that has no obvious cause.",
      "title": "Head, neck and oral cancer screening with the two-week lesion re-check rule",
      "trigger": "Every comprehensive or periodic exam; a soft-tissue lesion is found that has no obvious cause",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "source": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "cenp-006",
      "kind": "clinical",
      "materials": [
        "caries risk assessment form",
        "radiograph history",
        "recall scheduling system"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Diet and snacking frequency, fluoride exposure (water, toothpaste, supplements), saliva flow/dry mouth, prior caries history, visible plaque, and any restorations placed in the last 3 years.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Gather caries risk factors"
        },
        {
          "detail": "Assign caries risk level",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "low",
              "label": "Low risk"
            },
            {
              "goto": "s6",
              "id": "moderate",
              "label": "Moderate risk"
            },
            {
              "goto": "s7",
              "id": "high",
              "label": "High risk"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Assign caries risk level"
        },
        {
          "detail": "Recall in 6 months (or per practice policy); bitewings every 2–3 years for a low-risk adult with no new disease, per the ADA/FDA patient-selection guideline.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Set low-risk recall and bitewing interval"
        },
        {
          "detail": "Document: Risk level, contributing factors, and the chosen recall/bitewing interval entered in the chart and the recall scheduling system.\n\nRecord: Risk level, contributing factors, and the chosen recall/bitewing interval entered in the chart and the recall scheduling system.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Record risk level and set the recall schedule"
        },
        {
          "detail": "Risk level set, recall scheduled",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Risk level set, recall scheduled"
        },
        {
          "detail": "Recall in 6 months; bitewings on a shortened interval per practice policy, with targeted home-care coaching.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Set moderate-risk recall and bitewing interval"
        },
        {
          "detail": "Shorter recall interval (e.g. 3–4 months per practice policy); bitewings every 6–18 months per the ADA/FDA patient-selection guideline; consider fluoride varnish and diet counseling.\n\nWhy: High-risk patients need closer monitoring to catch new lesions before they require restorative treatment.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Set high-risk recall and bitewing interval",
          "why": "High-risk patients need closer monitoring to catch new lesions before they require restorative treatment."
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Caries risk assessment and risk-based recall and radiograph interval — The exam is complete; the risk level must be set before the recall interval and bitewing frequency are chosen.",
      "title": "Caries risk assessment and risk-based recall and radiograph interval",
      "trigger": "The exam is complete; the risk level must be set before the recall interval and bitewing frequency are chosen",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 World Workshop periodontal classification (staging/grading)",
          "source": "AAP 2017 World Workshop periodontal classification (staging/grading)",
          "url": "https://www.perio.org/"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 8,
      "frequency": "per-patient",
      "id": "cenp-007",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "explorer and mirror",
        "current-visit radiographs",
        "hygiene chart notes"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Use the practice's ready-signal method (light, flag, or software alert) once cleaning/scaling and updated charting are complete.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Signal the dentist that the patient is ready for exam"
        },
        {
          "detail": "Summarize anything notable: new sensitivity, bleeding points, a suspected lesion, or a patient concern raised during hygiene.\n\nWhy: A fast, targeted brief keeps the exam inside its time box without the dentist re-reviewing the full chart from scratch.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Brief the dentist in under a minute",
          "why": "A fast, targeted brief keeps the exam inside its time box without the dentist re-reviewing the full chart from scratch."
        },
        {
          "detail": "Quick soft-tissue check, review of current radiographs against prior films, spot-check hygiene charting for consistency, and address the patient's stated concern.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the time-boxed periodic exam"
        },
        {
          "detail": "Any new finding requiring more than a routine note?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "routine",
              "label": "Routine, nothing further needed"
            },
            {
              "goto": "s8",
              "id": "new-finding",
              "label": "New finding needs treatment planning or referral"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Any new finding requiring more than a routine note?"
        },
        {
          "detail": "The treating dentist personally confirms the exam findings (routine or escalated) are accurate and complete in the chart before the patient is dismissed to checkout.\n\nWhy: A periodic exam finding, even a routine one, is a licensed clinical judgment that must be the dentist's own confirmation, not an assistant's or hygienist's note left unconfirmed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the periodic exam before checkout.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the periodic exam before checkout",
          "why": "A periodic exam finding, even a routine one, is a licensed clinical judgment that must be the dentist's own confirmation, not an assistant's or hygienist's note left unconfirmed."
        },
        {
          "detail": "Document: Exam findings, any new items flagged, and next-recall confirmation entered in the chart with date and provider signature.\n\nRecord: Exam findings, any new items flagged, and next-recall confirmation entered in the chart with date and provider signature.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Record the periodic exam"
        },
        {
          "detail": "Periodic exam complete, patient dismissed to checkout",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Periodic exam complete, patient dismissed to checkout"
        },
        {
          "detail": "If it is a soft-tissue concern, follow the oral cancer screening protocol (cenp-005); if it is a restorative/perio finding, begin treatment planning outside this time-boxed visit.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Route the new finding to the appropriate follow-up protocol"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Periodic (recall) examination in the hygiene chair, time-boxed — The hygienist signals ready for the exam on an established patient.",
      "title": "Periodic (recall) examination in the hygiene chair, time-boxed",
      "trigger": "The hygienist signals ready for the exam on an established patient",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "source": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "cenp-008",
      "kind": "clinical",
      "materials": [
        "chief-complaint intake note",
        "explorer and mirror",
        "periapical radiograph as indicated",
        "pulp-testing supplies as needed"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record the patient's own words for the specific problem (e.g. broken tooth, sensitivity, lost filling) and when it started.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Capture the chief complaint at scheduling or check-in"
        },
        {
          "detail": "Does the complaint include emergency signs (facial swelling, severe uncontrolled pain, trauma with bleeding)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "not-emergency",
              "label": "No emergency signs"
            },
            {
              "goto": "s12",
              "id": "emergency-signs",
              "label": "Emergency signs present"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the complaint include emergency signs (facial swelling, severe uncontrolled pain, trauma with bleeding)?"
        },
        {
          "detail": "Re-confirm the specific tooth or area and symptom pattern (cold/hot/biting/spontaneous) directly with the patient before the dentist enters.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Seat the patient and confirm the complaint"
        },
        {
          "detail": "Visual and tactile exam limited to the area of complaint; percussion, palpation, and pulp testing as indicated by the symptom pattern.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the focused clinical exam"
        },
        {
          "detail": "Is a targeted radiograph indicated?",
          "forks": [
            {
              "advised": false,
              "goto": "s7",
              "id": "no-radiograph",
              "label": "No radiograph needed"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "radiograph",
              "label": "Take a targeted periapical radiograph"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a targeted radiograph indicated?"
        },
        {
          "detail": "Expose a periapical radiograph of the affected tooth/area only, per the ADA/FDA patient-selection guideline for a symptomatic tooth.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Take the targeted radiograph"
        },
        {
          "detail": "The treating dentist personally confirms the diagnosis for the specific complaint before same-day treatment proceeds or a treatment plan is presented.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on diagnosis before treatment or a treatment plan is offered.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on diagnosis before treatment or a treatment plan is offered"
        },
        {
          "detail": "Can this be resolved in today's visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "same-day",
              "label": "Same-day treatment appropriate"
            },
            {
              "goto": "s14",
              "id": "separate-visit",
              "label": "Needs a separate treatment appointment"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Can this be resolved in today's visit?"
        },
        {
          "detail": "Prepare the operatory and materials for the diagnosed same-day procedure, per the relevant restorative or emergency protocol.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to same-day treatment setup"
        },
        {
          "detail": "Document: Chief complaint, focused findings, radiograph if taken, diagnosis, and disposition (same-day vs. scheduled) entered in the chart.\n\nRecord: Chief complaint, focused findings, radiograph if taken, diagnosis, and disposition (same-day vs. scheduled) entered in the chart.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Record the limited exam and diagnosis"
        },
        {
          "detail": "Limited exam complete, disposition set",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Limited exam complete, disposition set"
        },
        {
          "detail": "If there are signs of a life-threatening emergency (difficulty breathing/swallowing, spreading facial swelling, uncontrolled bleeding), call 911 first. Otherwise, hand off to the emergency exam protocol (cenp-009) rather than continuing this limited exam.\n\nWhy: A problem-focused exam assumes a stable, non-emergency complaint; true emergency signs must be triaged before any routine exam step.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Redirect to emergency triage before this exam continues.",
            "type": "safety"
          },
          "id": "s12",
          "kind": "gate",
          "role": "front-desk",
          "title": "Redirect to emergency triage before this exam continues",
          "why": "A problem-focused exam assumes a stable, non-emergency complaint; true emergency signs must be triaged before any routine exam step."
        },
        {
          "detail": "Redirected to emergency triage protocol",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Redirected to emergency triage protocol"
        },
        {
          "detail": "Book the treatment appointment and communicate any interim home-care instructions the dentist provided.",
          "id": "s14",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to scheduling for a follow-up treatment appointment"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Limited, problem-focused examination — A patient presents with one specific complaint (broken tooth, sensitivity, lost filling).",
      "title": "Limited, problem-focused examination",
      "trigger": "A patient presents with one specific complaint (broken tooth, sensitivity, lost filling)",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "source": "ADA/FDA Dental Radiographic Examinations — recommendations for patient selection",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Life-threatening sign screening and same-day disposition script — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Life-threatening sign screening and same-day disposition script — generic functional equivalent"
          },
          "source": "Life-threatening sign screening and same-day disposition script — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "cenp-009",
      "kind": "clinical",
      "materials": [
        "emergency intake form",
        "pain scale card",
        "radiograph unit",
        "vitals kit (BP cuff, thermometer, pulse ox)",
        "phone/EMS line"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Before the exam begins: check for difficulty breathing or swallowing, swelling spreading toward the eye or down into the neck, uncontrolled bleeding, high fever with jaw lockjaw, facial trauma with loss of consciousness, or signs of a severe allergic reaction (hives, wheeze, throat tightness, facial/tongue swelling, or sudden hypotension). Call 911 immediately for any of these. For signs of a severe allergic reaction specifically: administer IM epinephrine from the office emergency kit immediately, then call 911 — do not wait for EMS to arrive before giving epinephrine. Position the patient for their presentation: an unconscious patient in the recovery position to protect the airway, a patient with shock or fainting signs supine with legs elevated, and a conscious patient in respiratory distress upright and calm. Do not proceed with the routine exam until EMS has responded.\n\nWhy: A dental-looking complaint can be the presentation of an airway or systemic emergency; the office is not equipped to manage those beyond stabilization and calling 911.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Screen for a true medical emergency before any exam step.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Screen for a true medical emergency before any exam step",
          "why": "A dental-looking complaint can be the presentation of an airway or systemic emergency; the office is not equipped to manage those beyond stabilization and calling 911."
        },
        {
          "detail": "Record blood pressure, pulse, temperature and a 0–10 pain scale rating; note onset, duration and what makes the pain better or worse.\n\nWhy: Baseline vitals catch a developing systemic problem and give the dentist an objective severity marker.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Take vitals and a pain scale reading",
          "why": "Baseline vitals catch a developing systemic problem and give the dentist an objective severity marker."
        },
        {
          "detail": "Ask about and record known drug allergies, anticoagulant or antiplatelet medication use, and any standing medical-alert flags in the chart before same-day treatment or a prescription is considered (cross-reference cenp-003 medical history and ASA classification).\n\nWhy: Same-day anesthesia, incision and drainage, and antibiotic prescribing all carry allergy and bleeding-risk exposure that must be checked before an irreversible step, not after.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Check drug allergies, anticoagulant/antiplatelet use, and medical-alert flags",
          "why": "Same-day anesthesia, incision and drainage, and antibiotic prescribing all carry allergy and bleeding-risk exposure that must be checked before an irreversible step, not after."
        },
        {
          "detail": "Ask onset, duration, quality, triggers (hot/cold/biting), prior treatment on the tooth or area, any trauma mechanism, and any self-treatment already tried.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Take a focused history of the present complaint"
        },
        {
          "detail": "Visual and tactile exam of the involved area: percussion, palpation, mobility, extent and firmness of any swelling, and a check for drainage or a visible fracture line.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the focused clinical exam"
        },
        {
          "detail": "Decide whether a targeted periapical radiograph taken in-office is enough, or whether the presentation (suspected jaw fracture, deep space swelling) needs advanced imaging the office cannot take.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "targeted-film",
              "label": "Take a targeted periapical radiograph in-office"
            },
            {
              "goto": "s15",
              "id": "advanced-imaging",
              "label": "Findings suggest a fracture or deep-space process — arrange advanced imaging before diagnosing"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Select the imaging needed to reach a diagnosis"
        },
        {
          "detail": "Combine history, exam and imaging to reach a working diagnosis: pulpal, periapical, periodontal abscess, cracked tooth, or traumatic injury, and note the extent of any swelling or infection.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Reach a working diagnosis"
        },
        {
          "detail": "The treating dentist signs off on the working diagnosis and the proposed disposition in the chart before any irreversible step (extraction, incision and drainage, antibiotic prescription) proceeds.\n\nWhy: An emergency visit moves fast; a documented sign-off point stops a rushed diagnosis from becoming an irreversible treatment without a deliberate check.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms diagnosis and disposition before treatment begins.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms diagnosis and disposition before treatment begins",
          "why": "An emergency visit moves fast; a documented sign-off point stops a rushed diagnosis from becoming an irreversible treatment without a deliberate check."
        },
        {
          "detail": "Choose whether the finding can be treated in-office today, needs a same-day specialist referral, or needs the hospital emergency department / on-call oral surgeon.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "treat-today",
              "label": "Within scope — treat today in-office"
            },
            {
              "goto": "s16",
              "id": "refer-specialist",
              "label": "Refer same-day to a specialist"
            },
            {
              "goto": "s17",
              "id": "send-ed",
              "label": "Send to the hospital ED or on-call oral surgeon"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide today's disposition"
        },
        {
          "detail": "Complete the urgent procedure within the office's scope (e.g., pulpotomy, incision and drainage, splinting a luxated tooth) and manage pain per office protocol.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the indicated same-day procedure"
        },
        {
          "detail": "Give written pain-management instructions, an antibiotic prescription if clinically indicated, warning signs that mean go to the ED, and a specific follow-up timeframe.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Give home-care and follow-up instructions"
        },
        {
          "detail": "Document: history, exam findings, imaging taken, working diagnosis, disposition, treatment performed or referral made, and home-care instructions given, in the permanent chart.\n\nRecord: Emergency exam note: findings, diagnosis, disposition, treatment/referral, instructions given.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Chart the emergency visit"
        },
        {
          "detail": "Book or queue a callback to the patient within 24 hours of same-day treatment to check on pain control, bleeding, and any warning signs given at discharge.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the 24-hour post-treatment callback"
        },
        {
          "detail": "Emergency visit closed with a documented disposition",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Emergency visit closed with a documented disposition"
        },
        {
          "detail": "Send the patient for panoramic or CBCT imaging (in-house if available, otherwise an imaging center or the ED) and hold the diagnosis until the images return.\n\nWhy: A periapical film cannot show a jaw fracture or the extent of a deep fascial-space infection.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Arrange advanced imaging",
          "why": "A periapical film cannot show a jaw fracture or the extent of a deep fascial-space infection."
        },
        {
          "detail": "Call the specialist's office directly, confirm they can see the patient today, and send a written summary of findings, imaging and working diagnosis with the patient.",
          "id": "s16",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to a specialist for same-day care"
        },
        {
          "detail": "Call the hospital ED or on-call oral surgeon to confirm the patient is expected, arrange transport if the patient cannot safely drive, and send findings with the patient.",
          "id": "s17",
          "kind": "step",
          "role": "front-desk",
          "title": "Arrange hospital-level care"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Emergency exam for pain, swelling or trauma with same-day disposition — A same-day emergency patient is seated with acute pain, swelling, bleeding or trauma and needs a diagnosis and plan today.",
      "title": "Emergency exam for pain, swelling or trauma with same-day disposition",
      "trigger": "A same-day emergency patient is seated with acute pain, swelling, bleeding or trauma and needs a diagnosis and plan today",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 World Workshop periodontal classification (staging/grading)",
          "source": "AAP 2017 World Workshop periodontal classification (staging/grading)",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Per-tooth and per-quadrant diagnosis and prognosis charting sequence — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Per-tooth and per-quadrant diagnosis and prognosis charting sequence — generic functional equivalent"
          },
          "source": "Per-tooth and per-quadrant diagnosis and prognosis charting sequence — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "cenp-010",
      "kind": "clinical",
      "materials": [
        "completed exam findings",
        "radiographs and photos",
        "perio chart",
        "risk assessment results",
        "chart / clinical record software"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull together hard- and soft-tissue exam findings, periodontal charting, radiographs, intraoral photos, and the completed risk assessments before diagnosing anything.\n\nWhy: A diagnosis reached from partial data misses findings that only show up when everything is viewed together (e.g., a radiolucency plus a mobility finding).",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Compile all exam data in one place",
          "why": "A diagnosis reached from partial data misses findings that only show up when everything is viewed together (e.g., a radiolucency plus a mobility finding)."
        },
        {
          "detail": "For each tooth, quadrant or site with an active finding, assign a diagnosis using standard categories: caries (by surface/depth), pulpal status, periodontal diagnosis staged and graded per the current periodontal classification, occlusal, and TMJ findings.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Assign a diagnosis to each active finding"
        },
        {
          "detail": "Cracked tooth vs pulpal disease, referred pain from an adjacent tooth, sinus involvement mimicking a maxillary posterior toothache, and non-odontogenic causes of facial pain.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Rule out alternative explanations before finalizing"
        },
        {
          "detail": "List every active problem in priority order: anything symptomatic or infection-risk first, then disease-control items, then restorative and elective items.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Build the prioritized problem list"
        },
        {
          "detail": "Rate each involved tooth hopeless, questionable, fair, good, or excellent, based on the diagnosis, bone support, and restorability.\n\nWhy: Prognosis drives sequencing later — a hopeless tooth changes what gets planned around it.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Assign a prognosis to each involved tooth",
          "why": "Prognosis drives sequencing later — a hopeless tooth changes what gets planned around it."
        },
        {
          "detail": "Chart the diagnosis, prioritized problem list and per-tooth prognosis in the permanent clinical record so it is available to whoever builds the treatment plan.\n\nRecord: Diagnosis, problem list and prognosis, per tooth/site, in the permanent chart.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Enter diagnosis, problem list and prognosis into the permanent chart"
        },
        {
          "detail": "Flag findings that do not need treatment now but should be re-checked at the next recall (e.g., a small watch area, an early lesion) with a specific re-check interval.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Flag non-urgent findings to monitor"
        },
        {
          "detail": "Pass the completed diagnosis, problem list and prognosis to treatment plan sequencing so the phases can be built from it.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to treatment plan sequencing"
        },
        {
          "detail": "Diagnosis, problem list and prognosis charted",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Diagnosis, problem list and prognosis charted"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Diagnosis, problem list and prognosis charting — All exam data, radiographs and photos are gathered and a diagnosis must be recorded before planning.",
      "title": "Diagnosis, problem list and prognosis charting",
      "trigger": "All exam data, radiographs and photos are gathered and a diagnosis must be recorded before planning",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Case presentation and treatment-plan sequencing scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Case presentation and treatment-plan sequencing scripts — generic functional equivalent"
          },
          "source": "Case presentation and treatment-plan sequencing scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "cenp-011",
      "kind": "clinical",
      "materials": [
        "finalized diagnosis and problem list",
        "fee schedule",
        "insurance benefit summary if available",
        "treatment-plan software or template"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Start from the charted diagnosis, problem list and per-tooth prognosis; do not re-derive it from raw exam data.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Pull the finalized diagnosis and problem list"
        },
        {
          "detail": "Pull out anything causing pain, active infection, or risk of rapid worsening — this phase is scheduled first regardless of the rest of the plan.\n\nWhy: Sequencing by urgency first, not by convenience or cost, is what keeps a treatment plan from letting a painful or infected tooth wait behind elective work.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the urgent/emergent phase",
          "why": "Sequencing by urgency first, not by convenience or cost, is what keeps a treatment plan from letting a painful or infected tooth wait behind elective work."
        },
        {
          "detail": "Group periodontal therapy, caries control (interim restorations, extraction of hopeless teeth), and any other items that stabilize disease before definitive work.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the disease-control phase"
        },
        {
          "detail": "Group definitive restorations, endodontics, crowns, and prosthetics needed once disease is controlled.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the restorative phase"
        },
        {
          "detail": "Decide whether elective or cosmetic items are shown as an optional phase in this presentation, or held back for a separate consult once core needs are addressed.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "include-elective",
              "label": "Include as a clearly labeled optional phase in this plan"
            },
            {
              "goto": "s6",
              "id": "defer-elective",
              "label": "Hold elective items for a separate consult later"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether to include an elective/cosmetic phase now"
        },
        {
          "detail": "Sequence phases so dependencies are respected — e.g., periodontal therapy before crown margins are placed, root canal treatment before a crown on the same tooth.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Order the phases by urgency and clinical dependency"
        },
        {
          "detail": "Use the fee schedule to estimate the number of visits and the cost for each phase, and note which procedures typically bundle into the same visit.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Estimate visits and cost per phase"
        },
        {
          "detail": "Where an insurance benefit summary is available, note annual maximum and benefit-year timing and whether splitting phases across benefit years changes the patient's out-of-pocket cost.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Factor in insurance benefit timing"
        },
        {
          "detail": "Produce a written plan listing each phase, the teeth/procedures in it, the sequence, and the estimated fee, ready for case presentation.\n\nRecord: Phased treatment plan document: phases, procedures, sequence, estimated fees.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Finalize the written treatment plan document"
        },
        {
          "detail": "Pass the finalized written plan to case presentation so it can be presented to the patient with alternatives and risks.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to case presentation"
        },
        {
          "detail": "Phased treatment plan finalized and ready to present",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Phased treatment plan finalized and ready to present"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Treatment plan sequencing — urgent, disease control, restorative, elective phases — Diagnosis is complete and more than one procedure is needed.",
      "title": "Treatment plan sequencing — urgent, disease control, restorative, elective phases",
      "trigger": "Diagnosis is complete and more than one procedure is needed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Case presentation and treatment-plan sequencing scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Case presentation and treatment-plan sequencing scripts — generic functional equivalent"
          },
          "source": "Case presentation and treatment-plan sequencing scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Informed-consent discussion of risks, benefits, alternatives and no-treatment consequences — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Informed-consent discussion of risks, benefits, alternatives and no-treatment consequences — generic functional equivalent"
          },
          "source": "Informed-consent discussion of risks, benefits, alternatives and no-treatment consequences — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "per-patient",
      "id": "cenp-012",
      "kind": "clinical",
      "materials": [
        "finalized written treatment plan",
        "radiographs and intraoral photos",
        "cost estimate",
        "consent form",
        "patient handout template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull the finalized written plan, relevant radiographs and intraoral photos, and the cost estimate before the patient sits down for the conversation.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Prepare the presentation materials"
        },
        {
          "detail": "Explain what was found and why treatment is being recommended, using the radiographs or photos to show the patient what is being discussed.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the diagnosis in plain language"
        },
        {
          "detail": "Present the recommended plan, at least one reasonable alternative (including a lower-cost or more conservative option where one exists), and the option of no treatment.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Present the recommended plan and at least one alternative"
        },
        {
          "detail": "For each option: risks, benefits, expected outcome, and — for no treatment — the specific consequences of leaving the condition untreated (e.g., progression, higher future cost, risk of losing the tooth).\n\nWhy: Informed consent requires the patient to hear what happens if they do nothing, not only what happens if they proceed.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss risks, benefits, alternatives and no-treatment consequences",
          "why": "Informed consent requires the patient to hear what happens if they do nothing, not only what happens if they proceed."
        },
        {
          "detail": "If used, an AI drafting tool can generate a plain-language written summary of the plan and options for the patient to take home; the dentist or treatment coordinator reviews and edits it before it is given to the patient, and the handout states: 'AI-generated — reviewed by a licensed provider before use' (AB 3030 disclosure).\n\nWhy: Any GenAI-generated communication that reaches a patient carries the AB 3030 disclosure and a provider review step before it is handed over.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Optionally generate a patient-friendly written summary",
          "why": "Any GenAI-generated communication that reaches a patient carries the AB 3030 disclosure and a provider review step before it is handed over."
        },
        {
          "detail": "Give the patient or caregiver time to ask questions about the diagnosis, the options, or the materials/technique before moving to cost.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Answer questions"
        },
        {
          "detail": "Walk through the cost estimate, any insurance estimate, and financing or payment-plan options for each phase of the plan.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Discuss cost and financing"
        },
        {
          "detail": "Before scheduling any treatment discussed today, obtain the patient's (or caregiver's) signed informed consent covering the risks, benefits, alternatives and no-treatment consequences just discussed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain informed consent before scheduling.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain informed consent before scheduling"
        },
        {
          "detail": "The patient chooses to proceed and schedule, or to decline or defer the plan.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "proceed",
              "label": "Proceed and schedule the accepted phase(s)"
            },
            {
              "goto": "s13",
              "id": "decline",
              "label": "Decline or defer treatment for now"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "patient",
          "title": "Patient decides how to proceed"
        },
        {
          "detail": "Schedule the accepted phase(s) and confirm any pre-appointment instructions or deposits required.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Schedule the accepted treatment"
        },
        {
          "detail": "Document what was presented, which materials (including any AI-drafted handout) were given, and the patient's decision.\n\nRecord: Case-presentation note: options presented, materials given, consent obtained or decline documented, decision.",
          "id": "s11",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Chart the presentation"
        },
        {
          "detail": "Case presented and patient decision recorded",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Case presented and patient decision recorded"
        },
        {
          "detail": "Chart that the patient was informed of the risks of no treatment and chose to decline or defer, including the specific consequences discussed.\n\nRecord: Informed-refusal or deferral note: options discussed, no-treatment consequences given, patient's decision.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the informed decline or deferral"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Case presentation with alternatives, risks and no-treatment consequences — The treatment plan is finalized and the patient is ready to hear options.",
      "title": "Case presentation with alternatives, risks and no-treatment consequences",
      "trigger": "The treatment plan is finalized and the patient is ready to hear options",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Independent-exam second-opinion review script — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Independent-exam second-opinion review script — generic functional equivalent"
          },
          "source": "Independent-exam second-opinion review script — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "cenp-013",
      "kind": "clinical",
      "materials": [
        "outside treatment plan / records brought by patient",
        "radiograph viewer",
        "second-opinion intake form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Collect the outside office's written treatment plan, any radiographs or images the patient brought, and note which office produced them and when.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Collect the outside plan and any records the patient brought"
        },
        {
          "detail": "Review the outside diagnosis, proposed treatment, and any radiographs or images provided before seeing the patient.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Review the outside diagnosis and imaging"
        },
        {
          "detail": "Examine the specific teeth or areas covered by the outside plan directly, rather than relying only on the outside records.\n\nWhy: A second opinion that only re-reads someone else's chart is not independent; the value is in an examiner who reached their own findings.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Perform an independent exam of the area in question",
          "why": "A second opinion that only re-reads someone else's chart is not independent; the value is in an examiner who reached their own findings."
        },
        {
          "detail": "Compare the independent exam findings and diagnosis to what the outside plan proposed, noting any agreement or divergence.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Compare own findings to the outside plan"
        },
        {
          "detail": "Decide whether the independent findings support the outside plan as proposed, or diverge on diagnosis, sequencing, or approach.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "concur",
              "label": "Findings align with the outside plan"
            },
            {
              "goto": "s10",
              "id": "disagree",
              "label": "Findings diverge from the outside plan"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether findings align with the outside plan"
        },
        {
          "detail": "Explain to the patient that the independent findings support the outside diagnosis, noting any differences in approach, sequencing, or cost this office would offer.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Explain agreement with the outside plan"
        },
        {
          "detail": "Give the patient a written summary of the second-opinion findings and chart the same summary in the patient's record.\n\nRecord: Second-opinion note: outside plan reviewed, independent findings, agreement or divergence, summary given to patient.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Provide and chart the written second-opinion summary"
        },
        {
          "detail": "If the patient wants to proceed with this office's plan, hand off to the treatment coordinator to schedule and present cost.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to scheduling if the patient wants to proceed"
        },
        {
          "detail": "Second opinion delivered and documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Second opinion delivered and documented"
        },
        {
          "detail": "Explain where the independent findings differ from the outside plan and why, and offer this office's own written plan as an alternative.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the differing diagnosis or plan"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Second-opinion request or outside treatment plan review — A patient brings another office's treatment plan and asks for an opinion.",
      "title": "Second-opinion request or outside treatment plan review",
      "trigger": "A patient brings another office's treatment plan and asks for an opinion",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Referral letter drafting and loop-closure tracking — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Referral letter drafting and loop-closure tracking — generic functional equivalent"
          },
          "source": "Referral letter drafting and loop-closure tracking — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "cenp-014",
      "kind": "clinical",
      "materials": [
        "referral network list",
        "referral letter template",
        "radiographs/photos to transfer",
        "referral tracking log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify the specific finding that needs a specialist (e.g., endodontic, periodontal, oral surgery, orthodontic) and note the urgency.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Determine the finding exceeds the office's scope"
        },
        {
          "detail": "Choose the appropriate specialty and a specific provider from the referral network list, factoring in the patient's insurance and location where relevant.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Select the specialist to refer to"
        },
        {
          "detail": "Radiographs, relevant chart notes, and any relevant photos — limited to what the specialist needs for this referral (HIPAA minimum-necessary standard).",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Compile the records to transfer"
        },
        {
          "detail": "Draft a letter stating the reason for referral, relevant history, working diagnosis, and urgency.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Draft the referral letter"
        },
        {
          "detail": "The referring dentist reviews the drafted letter and the compiled records for accuracy and completeness and signs off before anything is sent to the specialist.\n\nWhy: A referral letter drafted by staff (or with AI assistance) speaks for the dentist's clinical judgment and must be checked before it leaves the office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs off before sending.",
            "role": "referring dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs off before sending",
          "why": "A referral letter drafted by staff (or with AI assistance) speaks for the dentist's clinical judgment and must be checked before it leaves the office."
        },
        {
          "detail": "Transmit the signed-off letter and records to the specialist through a secure channel.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the referral securely"
        },
        {
          "detail": "Log the referral with date sent, specialist, reason, and the expected report-back date in the referral tracking log.\n\nRecord: Referral tracking entry: patient, specialist, reason, date sent, expected report-back date.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the referral in the tracking system"
        },
        {
          "detail": "Wait the standard follow-up window (two weeks, or sooner for an urgent referral) for the specialist's report to arrive.",
          "id": "s8",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1209600,
          "title": "Wait for the specialist's report"
        },
        {
          "detail": "Check whether the specialist's report arrived within the expected window.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "received",
              "label": "Report received"
            },
            {
              "goto": "s13",
              "id": "not-received",
              "label": "Report not received by the follow-up window"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "front-desk",
          "title": "Check whether the report has been received"
        },
        {
          "detail": "Import the specialist's report into the chart and update the problem list and treatment plan based on the specialist's findings.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Import the specialist's findings into the chart"
        },
        {
          "detail": "Document that the loop is closed — either the report was received and filed, or record the documented reason it was not (patient no-show, specialist delay) and the next follow-up step.\n\nRecord: Loop-closure note: report received and filed, or reason not received plus next step.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Document loop closure"
        },
        {
          "detail": "Referral sent and loop closed or actively tracked",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Referral sent and loop closed or actively tracked"
        },
        {
          "detail": "Call the specialist's office to check status, and call the patient to confirm they attended the appointment.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Escalate the outstanding referral"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Specialist referral letter, records transfer and loop closure — A finding exceeds the office's scope and must be referred out; the referral is tracked until the specialist's report returns.",
      "title": "Specialist referral letter, records transfer and loop closure",
      "trigger": "A finding exceeds the office's scope and must be referred out; the referral is tracked until the specialist's report returns",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Outside records request and chart-import workflow — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Outside records request and chart-import workflow — generic functional equivalent"
          },
          "source": "Outside records request and chart-import workflow — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "cenp-015",
      "kind": "clinical",
      "materials": [
        "records release/authorization form",
        "prior office contact information",
        "records tracking log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Determine which prior records are needed for the transferring patient: radiographs, periodontal charting, and recent treatment history.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify which records are needed"
        },
        {
          "detail": "Have the patient sign an authorization/release form naming the prior office and the specific records needed before any request is sent.\n\nWhy: The prior office cannot release records to a new practice without the patient's signed authorization; skipping this step just produces a request that gets refused.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Get the patient's signed authorization to release records.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "front-desk",
          "title": "Get the patient's signed authorization to release records",
          "why": "The prior office cannot release records to a new practice without the patient's signed authorization; skipping this step just produces a request that gets refused."
        },
        {
          "detail": "Send the signed authorization and request to the prior office or imaging center, by fax, secure email, or the request method they specify.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the signed request to the prior office"
        },
        {
          "detail": "Wait the standard follow-up window for the prior office to send the requested records.",
          "id": "s4",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 604800,
          "title": "Wait for the prior office to respond"
        },
        {
          "detail": "Check whether the requested records arrived within the follow-up window.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "received",
              "label": "Records received"
            },
            {
              "goto": "s10",
              "id": "not-received",
              "label": "Not received by the follow-up window"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Check whether records were received"
        },
        {
          "detail": "Check that radiographs are diagnostic quality and recent enough to use, and that chart records are legible and complete.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Verify the received records are usable"
        },
        {
          "detail": "Import the received records into the new chart and log the date and source of the received materials.\n\nRecord: Records-import note: source office, records received, date imported (or reason not received).",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Import received records into the chart"
        },
        {
          "detail": "Flag the newly imported records for the dentist's pre-visit chart and records review before the patient's appointment.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Flag for the dentist's pre-visit review"
        },
        {
          "detail": "Outside records requested, received or escalated, and imported",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Outside records requested, received or escalated, and imported"
        },
        {
          "detail": "Call the prior office again to confirm the request was received; if records still cannot be obtained in time, note that new radiographs may need to be taken instead.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Escalate the outstanding request"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Outside records and radiograph request, receipt and chart import — A patient transfers in and prior records or films are needed before imaging.",
      "title": "Outside records and radiograph request, receipt and chart import",
      "trigger": "A patient transfers in and prior records or films are needed before imaging",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Running-behind schedule recovery and patient-communication script — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Running-behind schedule recovery and patient-communication script — generic functional equivalent"
          },
          "source": "Running-behind schedule recovery and patient-communication script — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "cenp-016",
      "kind": "clinical",
      "materials": [
        "day sheet / schedule screen",
        "delay log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note that the doctor column is running more than 15 minutes behind and how many minutes behind it currently is.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Recognize and measure the delay"
        },
        {
          "detail": "List the remaining patients today with procedure type, complexity, and how flexible each visit is to shift or shorten.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Review the remaining column for the day"
        },
        {
          "detail": "Decide whether to proactively notify waiting patients and offer options, or let the delay continue to compound silently.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "notify-and-recover",
              "label": "Notify waiting patients now and actively recover the column"
            },
            {
              "goto": "s8",
              "id": "do-nothing",
              "label": "Continue without notifying patients and let the delay compound"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide how to recover the column"
        },
        {
          "detail": "Proactively inform patients still waiting of the delay and the estimated wait, and offer to reschedule, wait, or come back later in the day.\n\nWhy: A patient told about a delay tolerates it far better than one left wondering; silence is what turns a delay into a complaint.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify waiting patients of the delay",
          "why": "A patient told about a delay tolerates it far better than one left wondering; silence is what turns a delay into a complaint."
        },
        {
          "detail": "Decide which remaining patients can be seen by a hygienist under supervision, or by an associate if one is available, to relieve the doctor column.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Reprioritize the remaining column"
        },
        {
          "detail": "Move non-urgent, exam-only visits later in the day, or offer to reschedule to another day, to protect time for the remaining complex or urgent visits.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Move non-urgent visits later"
        },
        {
          "detail": "Update the team via the shared messaging system or huddle board so every operatory knows the adjusted times.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Update the team on the new schedule"
        },
        {
          "detail": "Log the delay's cause, duration, and which block or procedure type it started with, so recurring causes of running behind can be tracked over time.\n\nRecord: Delay log entry: date, minutes behind, cause, actions taken.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Log the delay for pattern tracking"
        },
        {
          "detail": "Column recovery actions taken and delay logged",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Column recovery actions taken and delay logged"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Doctor running behind — column triage — The doctor column is more than 15 minutes behind.",
      "title": "Doctor running behind — column triage",
      "trigger": "The doctor column is more than 15 minutes behind",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "End-of-day clinical close-out review — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "End-of-day clinical close-out review — generic functional equivalent"
          },
          "source": "End-of-day clinical close-out review — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "daily",
      "id": "cenp-017",
      "kind": "clinical",
      "materials": [
        "day sheet / schedule screen",
        "unsigned-note queue",
        "prescription log",
        "lab case tracker",
        "referral tracker",
        "callback list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Open the unsigned-note queue, prescription log, lab case tracker, referral tracker, and callback list for the day just finished.\n\nWhy: A single place to see everything left undone keeps items from silently rolling to the next day.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Pull the day's open-item lists",
          "why": "A single place to see everything left undone keeps items from silently rolling to the next day."
        },
        {
          "detail": "For each patient seen today: confirm the clinical note is complete, accurate, and signed before leaving.\n\nWhy: An unsigned note is a legal and billing gap that compounds the longer it sits open.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Review and sign every unsigned chart note from today",
          "why": "An unsigned note is a legal and billing gap that compounds the longer it sits open."
        },
        {
          "detail": "Cross-check the prescription log against the pharmacy transmission confirmation for each script written today.\n\nWhy: A written-but-untransmitted prescription is invisible to everyone until the patient calls back in pain.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm every prescription written today was actually transmitted",
          "why": "A written-but-untransmitted prescription is invisible to everyone until the patient calls back in pain."
        },
        {
          "detail": "Review the lab tracker for cases due back within 48 hours or already past due; flag any that need a follow-up call.\n\nWhy: A late lab case discovered the morning of the seat appointment forces a same-day reschedule the patient did not cause.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Check lab case status for anything due tomorrow or overdue",
          "why": "A late lab case discovered the morning of the seat appointment forces a same-day reschedule the patient did not cause."
        },
        {
          "detail": "For each referral made today, confirm the referral letter or note was written and filed (see cenp-018 for the inbound side).\n\nWhy: An undocumented referral leaves no record if the specialist never responds or the patient never goes.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm outbound referrals sent today were documented",
          "why": "An undocumented referral leaves no record if the specialist never responds or the patient never goes."
        },
        {
          "detail": "Post-op checks, patients who left with unanswered questions, and any patient the provider flagged during the day.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Review the callback list for patients who need a same-day or next-day call"
        },
        {
          "detail": "Judge whether any open item (a post-op complication callback, an urgent lab issue, a missed prescription) needs same-evening action.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "route-urgent",
              "label": "Route the urgent item now"
            },
            {
              "goto": "s9",
              "id": "log-for-morning",
              "label": "Log it for first-thing tomorrow"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Any item that cannot wait until morning?"
        },
        {
          "detail": "Pass the patient's callback need and the reason for urgency to whoever covers after-hours contact per the practice's on-call arrangement.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the urgent item to the on-call or front-desk process"
        },
        {
          "detail": "Note in the daily log: notes signed, prescriptions confirmed, lab cases flagged, referrals documented, callbacks assigned.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Record the day's closeout status"
        },
        {
          "detail": "End-of-day review complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "End-of-day review complete"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Provider end-of-day review (unsigned notes, pending prescriptions, lab, referrals, callbacks) — End of every clinical day.",
      "title": "Provider end-of-day review (unsigned notes, pending prescriptions, lab, referrals, callbacks)",
      "trigger": "End of every clinical day",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Referral acknowledgment and report-back workflow — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Referral acknowledgment and report-back workflow — generic functional equivalent"
          },
          "source": "Referral acknowledgment and report-back workflow — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "cenp-018",
      "kind": "clinical",
      "materials": [
        "referral intake form",
        "referring-provider contact record",
        "report-back letter template",
        "records-release/consent form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record the referring provider's name and contact information, the patient's information, and the stated reason for referral in the referral tracker.\n\nWhy: An unlogged referral is easy to lose track of and leaves the referring provider without a paper trail.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the inbound referral",
          "why": "An unlogged referral is easy to lose track of and leaves the referring provider without a paper trail."
        },
        {
          "detail": "Check whether the referral packet includes radiographs, chart notes, or images the practice will need for the visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "records-present",
              "label": "Records included — file them"
            },
            {
              "goto": "s10",
              "id": "records-missing",
              "label": "Records missing — request them"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Were records or images sent with the referral?"
        },
        {
          "detail": "Send a brief acknowledgment (call, fax, or secure message) confirming the referral was received and an appointment is being scheduled.\n\nWhy: A referring provider who hears nothing back is less likely to refer again.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Acknowledge receipt to the referring provider",
          "why": "A referring provider who hears nothing back is less likely to refer again."
        },
        {
          "detail": "Pass the patient's contact information and the urgency noted by the referring provider to whoever schedules appointments.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to scheduling to book the visit"
        },
        {
          "detail": "Conduct the exam relevant to the referral reason and record findings, differential considerations, and any recommended plan.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the exam or consult and form an impression"
        },
        {
          "detail": "Summarize findings, impression, and any treatment rendered or recommended in a letter addressed to the referring provider.\n\nWhy: The referring provider is still that patient's primary contact for their other care and needs to know what was found.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Draft the report-back letter to the referring provider",
          "why": "The referring provider is still that patient's primary contact for their other care and needs to know what was found."
        },
        {
          "detail": "Verify the patient has a signed release on file authorizing the practice to share findings with the referring provider before the letter goes out.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm records-release consent covers what is being sent back.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm records-release consent covers what is being sent back"
        },
        {
          "detail": "Send the letter via the agreed secure channel and log the date sent in the referral tracker.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Send the report-back letter and log it"
        },
        {
          "detail": "Referral loop closed",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Referral loop closed"
        },
        {
          "detail": "Contact the referring provider's office and request the records or images needed to plan the visit; note the signed release on file if required.\n\nWhy: Planning the visit without the referring provider's findings risks duplicate imaging or a missed detail they already know.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Request missing records from the referring office",
          "why": "Planning the visit without the referring provider's findings risks duplicate imaging or a missed detail they already know."
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Inbound referral receipt, acknowledgment and report back to the referring provider — A physician, specialist or another dentist refers a patient to the practice.",
      "title": "Inbound referral receipt, acknowledgment and report back to the referring provider",
      "trigger": "A physician, specialist or another dentist refers a patient to the practice",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "USPSTF oral cancer screening statement (public domain)",
          "source": "USPSTF oral cancer screening statement (public domain)",
          "url": "https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/oral-cancer-screening"
        },
        {
          "kind": "generic",
          "label": "Soft-tissue exam and lesion documentation practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Soft-tissue exam and lesion documentation practice — generic functional equivalent"
          },
          "source": "Soft-tissue exam and lesion documentation practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "cenp-020",
      "kind": "clinical",
      "materials": [
        "intraoral camera or ruler for lesion measurement",
        "soft-tissue exam light",
        "patient education handout on the identified condition"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note location, size, color, border, texture, duration reported by the patient, and associated symptoms (pain, burning).\n\nWhy: A complete description at first sight is the baseline the follow-up recheck will be compared against.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Examine and describe the lesion",
          "why": "A complete description at first sight is the baseline the follow-up recheck will be compared against."
        },
        {
          "detail": "Check for recent antibiotic or steroid inhaler use, denture wear, smoking, immune status, and any history of recurrent similar lesions.\n\nWhy: Common benign causes (candidiasis from an inhaler, angular cheilitis from ill-fitting dentures) are often traceable to a specific, fixable cause.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Review relevant medical and medication history",
          "why": "Common benign causes (candidiasis from an inhaler, angular cheilitis from ill-fitting dentures) are often traceable to a specific, fixable cause."
        },
        {
          "detail": "Take an intraoral photo for the chart if the patient consents; store per the practice's photo-consent process.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Photograph the lesion with consent"
        },
        {
          "detail": "Check for induration, non-healing beyond two to three weeks, unexplained bleeding, fixation to underlying tissue, or a presentation the dentist cannot confidently attribute to a benign cause.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "benign-pattern",
              "label": "Pattern consistent with a known benign cause"
            },
            {
              "goto": "s10",
              "id": "concerning-pattern",
              "label": "Feature present that does not fit a benign pattern"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the lesion show any feature inconsistent with a benign cause?"
        },
        {
          "detail": "Chart the working diagnosis (e.g. aphthous ulcer, oral candidiasis, lichen planus, angular cheilitis) and the condition-specific management: a topical protective paste and avoidance of irritating foods for an aphthous ulcer; a topical or systemic antifungal for oral candidiasis, per the prescriber's clinical judgment; monitoring with a biopsy referral if lichen planus shows erosive or atypical features; and denture-fit correction plus a topical antifungal for angular cheilitis associated with denture wear.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Record the working diagnosis and initial management"
        },
        {
          "detail": "Provide written home-care guidance and what to expect for time to resolution.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Give the patient education handout for the identified condition"
        },
        {
          "detail": "Book a recheck visit within the interval appropriate to the condition to confirm resolution.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Hand off to scheduling for a follow-up recheck"
        },
        {
          "detail": "Document the description, working diagnosis, management given, and the recheck date.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Record the finding, diagnosis, and management plan in the chart"
        },
        {
          "detail": "Benign condition diagnosed and management plan in place",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Benign condition diagnosed and management plan in place"
        },
        {
          "detail": "Send a referral describing the finding and the reason for concern; do not attempt to manage the lesion as benign.\n\nWhy: A lesion outside the clearly benign pattern belongs with a specialist rather than a wait-and-see approach in general practice.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to an oral surgeon or oral medicine specialist for further evaluation",
          "why": "A lesion outside the clearly benign pattern belongs with a specialist rather than a wait-and-see approach in general practice."
        },
        {
          "detail": "Lesion referred for further evaluation",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Lesion referred for further evaluation"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Benign oral mucosal condition diagnosis and management (aphthae, candidiasis, lichen planus, angular cheilitis) — A patient presents with a sore, white or red lesion with a clear benign cause.",
      "title": "Benign oral mucosal condition diagnosis and management (aphthae, candidiasis, lichen planus, angular cheilitis)",
      "trigger": "A patient presents with a sore, white or red lesion with a clear benign cause",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Sensitive-finding disclosure and referral conversation — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Sensitive-finding disclosure and referral conversation — generic functional equivalent"
          },
          "source": "Sensitive-finding disclosure and referral conversation — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "cenp-021",
      "kind": "clinical",
      "materials": [
        "private consult room",
        "erosion pattern photo documentation",
        "printed list of eating-disorder and GI referral resources",
        "national eating disorder helpline card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Chart the location (typically lingual/palatal surfaces), extent, and any parotid enlargement or perimolysis pattern, with photos where consented.\n\nWhy: An objective clinical record supports the conversation and any later referral without relying on memory.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Document the erosion pattern objectively",
          "why": "An objective clinical record supports the conversation and any later referral without relying on memory."
        },
        {
          "detail": "Check the patient's age before proceeding to the private conversation, since a minor implicates guardian involvement and possible mandated-reporting obligations.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "adult-patient",
              "label": "Patient is an adult"
            },
            {
              "goto": "s10",
              "id": "minor-patient",
              "label": "Patient is a minor"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient a minor?"
        },
        {
          "detail": "The treating dentist confirms they are prepared to raise a sensitive topic with care, or consults a supervising colleague on wording first.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the dentist has reviewed the approach before raising it with the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm the dentist has reviewed the approach before raising it with the patient"
        },
        {
          "detail": "Bring the patient to a private consult room, away from the open bay and other patients, before raising the finding.\n\nWhy: A sensitive topic raised within earshot of other patients or staff damages trust regardless of how it is worded.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Move the conversation to a private setting",
          "why": "A sensitive topic raised within earshot of other patients or staff damages trust regardless of how it is worded."
        },
        {
          "detail": "State what was observed in neutral clinical language and ask an open question about possible causes, without naming purging or an eating disorder first.\n\nWhy: Leading with an assumption risks the patient shutting down before the conversation can help them.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Describe the clinical finding without assuming a cause",
          "why": "Leading with an assumption risks the patient shutting down before the conversation can help them."
        },
        {
          "detail": "Note whether the patient offers an explanation (reflux, medication, diet) or becomes guarded, denies, or discloses something concerning.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "explains-cause",
              "label": "Patient offers a plausible explanation (reflux, medication)"
            },
            {
              "goto": "s11",
              "id": "guarded-or-discloses",
              "label": "Patient is guarded or discloses a concern"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "How does the patient respond?"
        },
        {
          "detail": "Provide a referral note describing the erosion pattern and the suspected reflux cause for the physician to evaluate.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to the patient's physician for a GI/reflux evaluation"
        },
        {
          "detail": "Document the clinical finding, that a private conversation occurred, and any referral or resource offered — described neutrally, without assumptions stated as fact.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Record the finding and the conversation outcome"
        },
        {
          "detail": "Sensitive conversation and referral pathway complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Sensitive conversation and referral pathway complete"
        },
        {
          "detail": "For a minor patient, determine whether a guardian will be involved in this conversation and whether the presentation meets the practice's threshold for a mandated-reporter consult regarding suspected neglect or self-harm, per state mandated-reporting law; document the determination before proceeding to the private conversation.\n\nWhy: A minor with this presentation carries guardian-involvement and mandated-reporting considerations that do not apply the same way to an adult patient.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Assess guardian involvement and mandated-reporting obligations for a minor patient",
          "why": "A minor with this presentation carries guardian-involvement and mandated-reporting considerations that do not apply the same way to an adult patient."
        },
        {
          "detail": "Offer the printed list of eating-disorder and counseling referral resources and let the patient take it without requiring them to confirm anything.\n\nWhy: Providing a path to help works even when the patient is not ready to discuss the cause directly.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Offer resources without pressuring disclosure",
          "why": "Providing a path to help works even when the patient is not ready to discuss the cause directly."
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Suspected eating disorder or reflux erosion pattern: sensitive conversation and referral — Lingual erosion, parotid enlargement or enamel loss suggests purging or reflux.",
      "title": "Suspected eating disorder or reflux erosion pattern: sensitive conversation and referral",
      "trigger": "Lingual erosion, parotid enlargement or enamel loss suggests purging or reflux",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Outside-work evaluation and remediation treatment planning — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Outside-work evaluation and remediation treatment planning — generic functional equivalent"
          },
          "source": "Outside-work evaluation and remediation treatment planning — Practice policy — no published authority governs this step."
        }
      ],
      "class": "occlusion-treatment-planning",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "cenp-022",
      "kind": "clinical",
      "materials": [
        "outside-records request form",
        "diagnostic imaging for the affected area",
        "informed-consent-for-remediation-treatment form",
        "written treatment plan template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask what treatment was performed, when, where, and what symptoms or problems have appeared since.\n\nWhy: The patient's account often points directly to which area and which type of prior work needs evaluation.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Listen to the patient's account of what was done and what is going wrong",
          "why": "The patient's account often points directly to which area and which type of prior work needs evaluation."
        },
        {
          "detail": "Examine the area as a new finding, without assuming the patient's or a prior provider's characterization of the problem is correct.\n\nWhy: Diagnosing and planning treatment based on the practice's own independent findings protects the patient and the practice's record if the case is later disputed.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Conduct an independent clinical exam of the affected area",
          "why": "Diagnosing and planning treatment based on the practice's own independent findings protects the patient and the practice's record if the case is later disputed."
        },
        {
          "detail": "Judge whether requesting records from the original provider would meaningfully help planning, versus proceeding on the practice's own diagnostics.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "request-records",
              "label": "Request outside records before finalizing the plan"
            },
            {
              "goto": "s5",
              "id": "proceed-without",
              "label": "Proceed on the practice's own diagnostics only"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "Are outside records or imaging available and useful?"
        },
        {
          "detail": "With the patient's signed authorization, request the records; note in the chart if no response is received within a reasonable window.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Send a records/imaging request to the original provider"
        },
        {
          "detail": "Obtain radiographs or other imaging appropriate to the affected area and symptoms, regardless of whether outside imaging is later obtained.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Take the diagnostic imaging needed to evaluate the affected area"
        },
        {
          "detail": "Base the diagnosis on the practice's own exam and diagnostics; describe the plan to the patient in terms of what will fix the current problem, without disparaging the prior provider or speculating about what they did.\n\nWhy: Speculating about another provider's care can create liability exposure and does not help the patient get treated.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Form an independent diagnosis and remediation plan",
          "why": "Speculating about another provider's care can create liability exposure and does not help the patient get treated."
        },
        {
          "detail": "Walk the patient through the remediation plan, expected visits, and cost using the standard treatment-plan presentation format.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the treatment plan with cost and timeline"
        },
        {
          "detail": "Review and sign the informed-consent-for-remediation-treatment form describing the plan, risks, and alternatives before any remediation treatment begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain informed consent for the remediation treatment.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain informed consent for the remediation treatment"
        },
        {
          "detail": "Judge whether the finding is within the practice's scope or needs a specialist (e.g. endodontic, periodontal, or oral-surgical remediation).",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "in-scope",
              "label": "In scope — proceed within the practice"
            },
            {
              "goto": "s12",
              "id": "needs-specialist",
              "label": "Refer to a specialist for remediation"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the remediation require a specialist referral?"
        },
        {
          "detail": "Document the exam findings, independent diagnosis, consented plan, and any specialist referral in the chart.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Record the independent diagnosis, plan, consent, and any referral"
        },
        {
          "detail": "Outside-work case evaluated and remediation plan in place",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Outside-work case evaluated and remediation plan in place"
        },
        {
          "detail": "Send a referral describing the independent diagnosis and requested remediation to the appropriate specialist.",
          "id": "s12",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to a specialist referral"
        }
      ],
      "subclass": "comprehensive-exam-diagnosis-and-treatment-planning",
      "summary": "Patient returns with complications from treatment abroad or at another office — A patient presents with failing work done overseas or elsewhere and asks the practice to fix it.",
      "title": "Patient returns with complications from treatment abroad or at another office",
      "trigger": "A patient presents with failing work done overseas or elsewhere and asks the practice to fix it",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.4 (in-repo waterline standard)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.4 (in-repo waterline standard)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "daily",
      "id": "cict-001",
      "kind": "clinical",
      "materials": [
        "waterline test strips or product test kit",
        "EPA-registered intermediate-level surface disinfectant",
        "disposable surface barriers",
        "PPE par stock",
        "sharps container"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Turn on the dental unit, chair, overhead light, and computer/imaging sensor. Confirm compressed air and water lines are live.\n\nWhy: Equipment needs a warm-up/self-test window before the first patient of the day.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Arrive and power on the operatory",
          "why": "Equipment needs a warm-up/self-test window before the first patient of the day."
        },
        {
          "detail": "Run the handpiece lines, air/water syringe, and ultrasonic scaler to drain for at least 2 minutes (per the practice's morning waterline-flush standard) before the first patient of the day.\n\nWhy: Overnight-stagnant water lets biofilm bacteria build past the 500 CFU/mL CDC threshold; the morning flush clears it.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Flush the waterlines",
          "why": "Overnight-stagnant water lets biofilm bacteria build past the 500 CFU/mL CDC threshold; the morning flush clears it."
        },
        {
          "detail": "Run water through the high-volume evacuator and saliva ejector lines and confirm strong, steady vacuum at both.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Check suction and vacuum"
        },
        {
          "detail": "Test the dental chair movement, operatory light, handpieces (spin test), and imaging sensor/panoramic unit for a ready signal.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Equipment self-test"
        },
        {
          "detail": "Place disposable barriers on: chair switches and controls, light handle, headrest, bracket tray, x-ray tubehead and exposure button, computer keyboard/mouse, and any touch screen.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Barrier placement"
        },
        {
          "detail": "Confirm par-level stock of gloves (all sizes), masks, eye protection, cotton rolls/gauze, anesthetic cartridges and needles, and single-use items for the day's scheduled procedures.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Stock par check"
        },
        {
          "detail": "Confirm the sharps container is below three-quarters full and the regulated medical waste bin has a liner; replace either if needed.\n\nWhy: OSHA 29 CFR 1910.1030 sets the three-quarters-full replacement threshold for sharps containers.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Sharps and waste check",
          "why": "OSHA 29 CFR 1910.1030 sets the three-quarters-full replacement threshold for sharps containers."
        },
        {
          "detail": "Is the room fully ready?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "ready",
              "label": "Everything tested, stocked, and passing"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "issue",
              "label": "Something is missing, broken, or fails self-test"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the room fully ready?"
        },
        {
          "detail": "Tell the front desk/scheduler the operatory is ready to seat the first patient.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Mark room ready"
        },
        {
          "detail": "Record waterline flush time, equipment check outcome, and any shortfall note in the daily equipment/room readiness log.\n\nRecord: Daily room readiness log (non-clinical, equipment/room state only)",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Log room readiness"
        },
        {
          "detail": "Operatory ready for first patient",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Operatory ready for first patient"
        },
        {
          "detail": "Notify whoever holds ordering/repair authority for the practice that day, immediately, with what's missing or broken and which appointment it affects.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Escalate the shortfall"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Morning operatory startup — waterline flush, suction check, equipment test, barriers and stock — The first appointment of the day in each operatory.",
      "title": "Morning operatory startup — waterline flush, suction check, equipment test, barriers and stock",
      "trigger": "The first appointment of the day in each operatory",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "statute",
          "label": "State dental practice act scope for assistants (California B&P §§1750–1777) — delegation and supervision levels",
          "source": "State dental practice act scope for assistants (California B&P §§1750–1777) — delegation and supervision levels",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.2 (in-repo instrument reprocessing/Spaulding classification)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.2 (in-repo instrument reprocessing/Spaulding classification)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "cict-002",
      "kind": "clinical",
      "materials": [
        "procedure-specific sterile instrument cassette",
        "disposable tray covers",
        "procedure-specific consumables per manufacturer instructions",
        "written or laminated setup card per procedure type"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm procedure type (hygiene, restorative, crown, endo, surgical, pediatric) and any special needs (isolation, sedation, special instrument) from the day sheet.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Read the huddle sheet for procedure type"
        },
        {
          "detail": "Select the pre-packed sterile instrument cassette or tray for that procedure type from the sterilization area; confirm the sterilization indicator (autoclave tape/integrator strip) shows a pass.\n\nWhy: A failed sterilization indicator means the tray cannot be used until reprocessed.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Pull the matching sterile cassette",
          "why": "A failed sterilization indicator means the tray cannot be used until reprocessed."
        },
        {
          "detail": "Open the cassette onto the covered bracket tray without touching the sterile field with bare hands; arrange instruments in the order they'll be used.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Set up the operatory tray"
        },
        {
          "detail": "Add what the procedure needs: restorative — matrix bands, curing light shield, bonding materials; crown — impression material, temporary cement, shade guide; endo — files, irrigation solution, rubber dam kit; surgical — sutures, hemostatic agent, extra gauze; pediatric — smaller-sized instruments and behavior-guidance aids.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Add procedure-specific consumables"
        },
        {
          "detail": "Attach the correct handpiece(s) and load the bur block with the burs the procedure calls for.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Stage handpieces and burs"
        },
        {
          "detail": "Does this procedure need extra items beyond the standard cassette?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "standard",
              "label": "Standard cassette covers it"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "extra",
              "label": "Needs a supplemental item (e.g., surgical kit, rubber dam)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Does this procedure need extra items beyond the standard cassette?"
        },
        {
          "detail": "Compare the tray against the written or laminated setup card for that procedure type before the patient is seated.\n\nWhy: Catches a missing or wrong instrument before it becomes a mid-procedure delay.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Final visual check against the setup card",
          "why": "Catches a missing or wrong instrument before it becomes a mid-procedure delay."
        },
        {
          "detail": "If anything was substituted or added beyond the standard tray, note it briefly for the sterilization tech restocking after the appointment.\n\nRecord: Chairside setup note (non-clinical, tray contents only)",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Note any deviation from standard setup"
        },
        {
          "detail": "Room and tray staged for the specific procedure",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Room and tray staged for the specific procedure"
        },
        {
          "detail": "Retrieve the additional sterile kit or instrument from central sterilization and add it to the tray, confirming its sterilization indicator.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Pull the supplemental sterile kit"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Procedure-specific tray, cassette and operatory setup (hygiene, restorative, crown, endo, surgical, pediatric) — The next appointment type is known from the huddle sheet and the room is clean.",
      "title": "Procedure-specific tray, cassette and operatory setup (hygiene, restorative, crown, endo, surgical, pediatric)",
      "trigger": "The next appointment type is known from the huddle sheet and the room is clean",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State dental practice act scope for assistants (California B&P §§1750–1777) — delegation and supervision levels",
          "source": "State dental practice act scope for assistants (California B&P §§1750–1777) — delegation and supervision levels",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3.1 (in-repo pre-injection/history assessment context)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3.1 (in-repo pre-injection/history assessment context)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "cict-003",
      "kind": "clinical",
      "materials": [
        "updated medical history form",
        "vitals equipment (blood pressure cuff, pulse oximeter) if indicated",
        "medication list reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Call the patient by name, confirm identity with a second identifier per office policy, and walk them to the assigned operatory.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Greet and escort the patient"
        },
        {
          "detail": "Seat the patient, adjust chair position and headrest, offer a bib and protective eyewear.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Seat the patient"
        },
        {
          "detail": "Ask the patient to confirm or update their medical history, allergies, and current medications since the last visit; flag any new condition or medication change.\n\nWhy: An outdated history is one of the most common causes of an avoidable chairside drug interaction or allergic reaction.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Review and update the medical history",
          "why": "An outdated history is one of the most common causes of an avoidable chairside drug interaction or allergic reaction."
        },
        {
          "detail": "Is there a new or changed condition, allergy, or medication?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "none",
              "label": "No changes since last visit"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "change",
              "label": "A new condition, allergy, or medication is present"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Is there a new or changed condition, allergy, or medication?"
        },
        {
          "detail": "Are vitals indicated for this visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "routine",
              "label": "Not indicated (routine, low-risk visit per office policy)"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "indicated",
              "label": "Indicated (new patient, medical risk factor, sedation, or protocol requirement)"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Are vitals indicated for this visit?"
        },
        {
          "detail": "Ask the patient to state, in their own words, why they're here today and note it for the chart.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm chief complaint"
        },
        {
          "detail": "Enter the confirmed/updated history, any flagged change, vitals taken, and chief complaint into the patient chart.\n\nRecord: Patient chart — history update, vitals, chief complaint (PHI; on-device/PMS only, never a public path)",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Document history update, vitals, and chief complaint"
        },
        {
          "detail": "Tell the hygienist or dentist the patient is seated, history reviewed, and ready for exam.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to the treating provider"
        },
        {
          "detail": "Patient ready for provider",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Patient ready for provider"
        },
        {
          "detail": "Bring the updated history to the hygienist or dentist before any instrumentation begins so they can assess whether it changes today's plan (e.g., premedication, anesthesia choice).",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Flag the change to the treating provider"
        },
        {
          "detail": "Take blood pressure, pulse, and any other indicated vital sign; record the readings.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Take vitals"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Patient seating, medical history and medication reconciliation, vitals as indicated — A patient is escorted to the operatory.",
      "title": "Patient seating, medical history and medication reconciliation, vitals as indicated",
      "trigger": "A patient is escorted to the operatory",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 (in-repo standard precautions)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 (in-repo standard precautions)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "cict-004",
      "kind": "clinical",
      "materials": [
        "gloves (multiple sizes)",
        "surgical masks",
        "N95 or equivalent-filtration respirators",
        "eye protection or full face shields",
        "fluid-resistant gowns or protective clothing"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Classify the next procedure as standard-contact (exam, consult) or aerosol-generating (handpiece, ultrasonic scaler, air polishing, extraction) using the day sheet.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Determine the PPE tier for the next procedure"
        },
        {
          "detail": "For every patient contact at minimum: gloves, surgical mask, and eye protection.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Standard precautions PPE (all patients, no exceptions)"
        },
        {
          "detail": "Is this an aerosol-generating procedure?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "aerosol",
              "label": "Yes — upgrade PPE tier"
            },
            {
              "advised": false,
              "goto": "s6",
              "id": "standard",
              "label": "No — standard precautions are sufficient"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is this an aerosol-generating procedure?"
        },
        {
          "detail": "Add: N95 or higher-filtration respirator (fit-tested), full face shield or goggles plus mask, and a fluid-resistant gown or protective clothing.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Aerosol-tier PPE"
        },
        {
          "detail": "Perform a seal check on the N95/respirator each time it is donned; do not proceed if the seal fails.\n\nWhy: An unsealed respirator provides little more protection than a surgical mask against aerosols.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Fit-check the respirator",
          "why": "An unsealed respirator provides little more protection than a surgical mask against aerosols."
        },
        {
          "detail": "Don in this order: hand hygiene, gown, mask/respirator, eye protection, gloves last (gloves go on after everything else and cover the gown cuffs).\n\nWhy: Putting gloves on last keeps the cleanest barrier over any contamination picked up donning the earlier items.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Donning sequence",
          "why": "Putting gloves on last keeps the cleanest barrier over any contamination picked up donning the earlier items."
        },
        {
          "detail": "Doff in this order, away from the patient and other staff: gloves, then hand hygiene, then eye protection, then gown, then mask/respirator last, then hand hygiene again.\n\nWhy: Removing gloves first and the mask last is the CDC-recommended order to avoid self-contaminating the face.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Doffing sequence",
          "why": "Removing gloves first and the mask last is the CDC-recommended order to avoid self-contaminating the face."
        },
        {
          "detail": "Discard single-use PPE into the regulated waste stream if contaminated; wipe reusable eye protection and face shields with an EPA-registered disinfectant between patients.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Discard or reprocess"
        },
        {
          "detail": "If a respirator was reused across patients under crisis-capacity guidance, or a breach occurred (e.g., glove tear, splash to skin), note it for the compliance officer.\n\nRecord: PPE exception/incident note",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Note any PPE breach or reuse-beyond-guidance"
        },
        {
          "detail": "PPE cycle complete for this patient encounter",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "PPE cycle complete for this patient encounter"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "PPE selection, donning and doffing sequence by procedure aerosol level — Any patient contact; an aerosol-generating procedure is planned.",
      "title": "PPE selection, donning and doffing sequence by procedure aerosol level",
      "trigger": "Any patient contact; an aerosol-generating procedure is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 (in-repo standard precautions, hand hygiene moments)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 (in-repo standard precautions, hand hygiene moments)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 1,
      "frequency": "per-use",
      "id": "cict-005",
      "kind": "clinical",
      "materials": [
        "soap-and-water handwashing station",
        "alcohol-based hand rub (ABHR)",
        "single-use paper towels"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "The required moments include: before gloving, after removing gloves, between patients, after touching a contaminated surface, and after using the restroom or eating.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Identify the hand hygiene moment"
        },
        {
          "detail": "Are hands visibly soiled?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "soiled",
              "label": "Yes — visibly soiled or contaminated"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "not-soiled",
              "label": "No — not visibly soiled"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Are hands visibly soiled?"
        },
        {
          "detail": "Wet hands, apply soap, lather covering all surfaces (palms, backs, between fingers, thumbs, fingertips, nails) for at least 20 seconds, rinse, and dry with a single-use paper towel.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Wash with soap and water"
        },
        {
          "detail": "Do not glove over wet hands.\n\nWhy: Wet hands under gloves increase glove permeability and skin irritation over a shift.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm hands are fully dry before gloving",
          "why": "Wet hands under gloves increase glove permeability and skin irritation over a shift."
        },
        {
          "detail": "Don gloves sized to the wearer; change gloves between patients and any time they are torn or visibly soiled.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Glove"
        },
        {
          "detail": "Before touching a patient, before a clean or aseptic task, after body-fluid exposure risk, after touching a patient, after touching patient surroundings, and after glove removal.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Situations that always require a fresh hand hygiene cycle"
        },
        {
          "detail": "If a soap, ABHR, or towel dispenser is empty or broken, report it immediately rather than skip the moment.\n\nRecord: Facility supply/maintenance note",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Report dispenser or supply failures"
        },
        {
          "detail": "Hand hygiene moment complete",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand hygiene moment complete"
        },
        {
          "detail": "Apply enough ABHR to cover all hand surfaces and rub until dry, at least 20 seconds; this is the preferred method when hands are not visibly soiled.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Use alcohol-based hand rub"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Hand hygiene moments and technique — Before gloving, after degloving, between patients, after touching surfaces.",
      "title": "Hand hygiene moments and technique",
      "trigger": "Before gloving, after degloving, between patients, after touching surfaces",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.3 (in-repo surface disinfection)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.3 (in-repo surface disinfection)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "cict-006",
      "kind": "clinical",
      "materials": [
        "disposable plastic barriers/sleeves",
        "EPA-registered intermediate-level disinfectant"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "High-touch surfaces that are hard to wipe (switches, handles, tubehead, keyboard) get a disposable barrier; smooth uncovered surfaces get direct disinfection.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Identify barrier vs. direct-disinfection surfaces"
        },
        {
          "detail": "Chair controls, light handle and switch, headrest, bracket tray, x-ray tubehead and exposure button, computer keyboard/mouse or touchscreen, air/water syringe buttons.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Barrier every surface on the list"
        },
        {
          "detail": "After the patient is dismissed, remove all barriers with gloved hands, taking care not to touch the surface underneath.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Remove barriers between patients"
        },
        {
          "detail": "Wipe every surface (barriered and unbarriered) with an EPA-registered intermediate-level disinfectant, keeping the surface visibly wet for the label's full contact time (typically 1–3 minutes).\n\nWhy: Contact time, not just wiping, is what kills the organisms the disinfectant is rated for.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the exposed surfaces",
          "why": "Contact time, not just wiping, is what kills the organisms the disinfectant is rated for."
        },
        {
          "detail": "Once surfaces are dry, apply new disposable barriers before the next patient is seated.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Apply fresh barriers"
        },
        {
          "detail": "Did a barrier fail during the appointment?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "intact",
              "label": "No — barriers stayed intact"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "failed",
              "label": "Yes — a barrier failed mid-appointment (torn, slipped, or contaminated)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Did a barrier fail during the appointment?"
        },
        {
          "detail": "Note barrier change and disinfection completed as part of the between-patient turnover log.\n\nRecord: Turnover checklist entry",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the turnover"
        },
        {
          "detail": "Barriers refreshed for the next patient",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Barriers refreshed for the next patient"
        },
        {
          "detail": "Stop and disinfect the surface under a failed barrier as soon as it's noticed; don't wait for turnover.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the exposed surface immediately"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Surface barrier placement and change between patients — The room is being prepared for a patient.",
      "title": "Surface barrier placement and change between patients",
      "trigger": "The room is being prepared for a patient",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "cict-007",
      "kind": "clinical",
      "materials": [
        "high-volume evacuator (HVE) tip",
        "rubber dam kit",
        "antimicrobial pre-procedural rinse per office protocol",
        "dental dam clamp/frame"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Ultrasonic scaling, high-speed handpiece use, and air polishing are aerosol-generating; plan isolation and evacuation before starting.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the procedure generates aerosols"
        },
        {
          "detail": "Have the patient rinse with the office's antimicrobial rinse for 30–60 seconds before the procedure begins, unless contraindicated (e.g., allergy, or a young child who cannot rinse and spit).\n\nWhy: Pre-procedural rinsing reduces the microbial load of the aerosol produced.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Offer the pre-procedural antimicrobial rinse",
          "why": "Pre-procedural rinsing reduces the microbial load of the aerosol produced."
        },
        {
          "detail": "Is rubber dam isolation appropriate for this procedure?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "dam",
              "label": "Yes — use rubber dam isolation"
            },
            {
              "advised": false,
              "goto": "s5",
              "id": "no-dam",
              "label": "No — procedure doesn't allow dam isolation (e.g., scaling, crown seating)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is rubber dam isolation appropriate for this procedure?"
        },
        {
          "detail": "Isolate the operative field with a rubber dam per the procedure's clamp and frame selection.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Place the rubber dam"
        },
        {
          "detail": "Keep the HVE tip within about 1 inch of the aerosol source throughout the procedure, held by the assistant or a dental dam clip.\n\nWhy: HVE positioned close to the source captures the large majority of aerosol and spatter before it disperses.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Position high-volume evacuation",
          "why": "HVE positioned close to the source captures the large majority of aerosol and spatter before it disperses."
        },
        {
          "detail": "Maintain continuous suction and retraction technique through the aerosol-generating portion of the procedure.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Coordinate suction and retraction"
        },
        {
          "detail": "After the aerosol-generating portion ends, allow the room's ventilation/air-turnover time (per the office's HVAC settings) before the next patient enters, if the room lacks supplemental air filtration.\n\nWhy: Aerosols remain suspended for a period after the procedure stops; clearance time reduces the next patient's and staff's exposure.",
          "id": "s7",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 900,
          "title": "Allow post-procedure air clearance",
          "why": "Aerosols remain suspended for a period after the procedure stops; clearance time reduces the next patient's and staff's exposure."
        },
        {
          "detail": "Once clearance time has elapsed, proceed to the standard between-patient turnover (barrier removal, disinfection, waste).",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Proceed to standard turnover"
        },
        {
          "detail": "Note the aerosol-generating procedure performed, HVE use, and clearance time observed.\n\nRecord: Aerosol/turnover log entry",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Log the aerosol procedure and clearance"
        },
        {
          "detail": "Aerosol-generating procedure closed out safely",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Aerosol-generating procedure closed out safely"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Aerosol management — high-volume evacuation, isolation, pre-procedural rinse, room clearance after the procedure — Ultrasonic scaling, a high-speed handpiece or air polishing is planned.",
      "title": "Aerosol management — high-volume evacuation, isolation, pre-procedural rinse, room clearance after the procedure",
      "trigger": "Ultrasonic scaling, a high-speed handpiece or air polishing is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.3, §1.6 (in-repo surface disinfection and sharps safety)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.3, §1.6 (in-repo surface disinfection and sharps safety)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "cict-008",
      "kind": "clinical",
      "materials": [
        "puncture-resistant sharps container",
        "regulated medical waste bag",
        "covered instrument transport container",
        "EPA-registered intermediate-level disinfectant",
        "fresh disposable barriers"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Walk the patient out, hand off any post-procedure instructions, and confirm the next appointment if applicable.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Dismiss the patient"
        },
        {
          "detail": "Using one-handed technique, drop used needles, scalpel blades, and other sharps directly into the puncture-resistant sharps container at point of use; never recap two-handed.\n\nWhy: The OSHA bloodborne pathogens standard requires immediate, one-handed sharps disposal at the point of use.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Remove and dispose of sharps",
          "why": "The OSHA bloodborne pathogens standard requires immediate, one-handed sharps disposal at the point of use."
        },
        {
          "detail": "Place gauze, cotton rolls, and other blood/OPIM-soaked items into the regulated medical waste bag; tie and remove if full.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Bag and remove other regulated waste"
        },
        {
          "detail": "Close the used cassette or place loose instruments into a covered transport container and carry it to central sterilization without recontacting clean surfaces on the way.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Transport used instruments to sterilization"
        },
        {
          "detail": "Wipe visibly soiled surfaces first to remove debris, discard the soiled wipe, then wipe again with a fresh disinfectant wipe and leave surfaces wet for the full label contact time.\n\nWhy: Wiping once over visible debris can smear contamination instead of removing it; the second wipe is what actually disinfects.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Wipe-discard-wipe the operatory",
          "why": "Wiping once over visible debris can smear contamination instead of removing it; the second wipe is what actually disinfects."
        },
        {
          "detail": "Remove used barriers with gloved hands and apply fresh barriers to all listed high-touch surfaces.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Remove and replace barriers"
        },
        {
          "detail": "Target a complete turnover (waste, transport, disinfection, barriers, restock) within the office's set turnover window, commonly around 10 minutes for a routine visit.\n\nWhy: A defined target keeps the schedule on time without shortcutting infection-control steps.",
          "id": "s7",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 600,
          "title": "Hit the turnover time target",
          "why": "A defined target keeps the schedule on time without shortcutting infection-control steps."
        },
        {
          "detail": "Replace anything used from the room's par stock: gloves, cotton products, disposable tips, barriers.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Restock consumables used during the visit"
        },
        {
          "detail": "Do a final visual scan of the room — no visible debris, all barriers fresh, sharps/waste containers not overfull, tray set for the next patient — before calling the next patient back.\n\nWhy: A final look-over is the last chance to catch a missed step before a patient is in the room.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Final visual verification before the next patient is seated",
          "why": "A final look-over is the last chance to catch a missed step before a patient is in the room."
        },
        {
          "detail": "Did the visual check pass?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "pass",
              "label": "Room passes visual check"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "fail",
              "label": "Something still needs fixing"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "assistant",
          "title": "Did the visual check pass?"
        },
        {
          "detail": "Tell the front desk/scheduler the room is ready so the next patient can be brought back.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Room ready — signal front desk"
        },
        {
          "detail": "Log turnover completion time and any note from the visual check in the daily turnover log.\n\nRecord: Turnover completion log",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Log turnover completion"
        },
        {
          "detail": "Turnover complete, room ready for next patient",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Turnover complete, room ready for next patient"
        },
        {
          "detail": "Correct whatever the visual check caught (missing barrier, overfull sharps container, leftover debris) before the next patient enters the room.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Fix the gap before seating"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Between-patient turnover — sharps, waste, instrument transport, wipe-discard-wipe, timed target and visual verification before seating — A patient is dismissed and the next patient is waiting.",
      "title": "Between-patient turnover — sharps, waste, instrument transport, wipe-discard-wipe, timed target and visual verification before seating",
      "trigger": "A patient is dismissed and the next patient is waiting",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.4 Dental Unit Waterlines (DUWL)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.4 Dental Unit Waterlines (DUWL)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California minimum standards for infection control (16 CCR §1005)",
          "source": "Dental Board of California minimum standards for infection control (16 CCR §1005)",
          "url": "https://www.dbc.ca.gov/"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "daily",
      "id": "cict-009",
      "kind": "clinical",
      "materials": [
        "waterline test strips",
        "waterline treatment tablets or solution",
        "timer",
        "PPE",
        "waterline log sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Before the first patient, run water through each handpiece line, air/water syringe and ultrasonic scaler for at least 2 minutes with no handpiece attached.\n\nWhy: Overnight and weekend stagnation lets biofilm regrow inside the tubing; the CDC public guidance calls for a purge before first use each day.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Flush all waterlines at the start of the day",
          "why": "Overnight and weekend stagnation lets biofilm regrow inside the tubing; the CDC public guidance calls for a purge before first use each day."
        },
        {
          "detail": "Run water through each line for 20-30 seconds after every patient, with the handpiece removed, into the cuspidor or a container.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Flush lines between patients"
        },
        {
          "detail": "Initial the waterline log sheet for the operatory with date, time and staff initials confirming the morning flush was performed.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Log the daily flush"
        },
        {
          "detail": "Is today the scheduled day for periodic waterline treatment (weekly or monthly per product label)?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "yes",
              "label": "Yes — treatment is due today"
            },
            {
              "advised": false,
              "goto": "s8",
              "id": "no",
              "label": "No — treatment already current"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "title": "Is today the scheduled day for periodic waterline treatment (weekly or monthly per product label)?"
        },
        {
          "detail": "Sterilization tech mixes the treatment tablet or solution per the product label instructions and dispenses it into the water bottle or system reservoir.\n\nWhy: Only the product label's own dilution and dwell time are validated for that product; improvised concentrations can under-treat or damage tubing.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Prepare the waterline treatment solution",
          "why": "Only the product label's own dilution and dwell time are validated for that product; improvised concentrations can under-treat or damage tubing."
        },
        {
          "detail": "Leave the treatment solution in the lines for the dwell time printed on the product label before flushing it out.",
          "id": "s6",
          "kind": "timer",
          "role": "sterilization-tech",
          "timer_seconds": 600,
          "title": "Let the treatment dwell per label instructions"
        },
        {
          "detail": "Run fresh water through every line until no odor or residue of the treatment product remains, per label guidance.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Flush treatment solution from all lines"
        },
        {
          "detail": "Run a waterline test strip on a sample line per the testing schedule; confirm the result meets the target set by the treatment product (public dental unit water should be no worse than potable water quality).",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Periodic water-quality test-strip check"
        },
        {
          "detail": "Did the test strip pass?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "pass",
              "label": "Result within target range"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "fail",
              "label": "Result out of range"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "title": "Did the test strip pass?"
        },
        {
          "detail": "Record the treatment date, product lot, dwell time and test-strip result on the waterline log sheet.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the treatment and test result"
        },
        {
          "detail": "Waterline maintenance complete for this cycle",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Waterline maintenance complete for this cycle"
        },
        {
          "detail": "Sterilization tech flags the failed result to the practice owner or dentist immediately; the office manager or dentist decides whether to take the operatory out of clinical use for non-emergency procedures pending a shock-treatment or plumbing fix, and that decision is recorded in the log.\n\nWhy: A failed water-quality result means the line needs remediation before it is used for patient care, not just another routine flush.",
          "id": "s12",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Escalate an out-of-range result to the practice owner",
          "why": "A failed water-quality result means the line needs remediation before it is used for patient care, not just another routine flush."
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Dental unit waterline daily flush and weekly or monthly treatment per product — Daily flush at open and between patients; weekly or monthly treatment per the product schedule.",
      "title": "Dental unit waterline daily flush and weekly or monthly treatment per product",
      "trigger": "Daily flush at open and between patients; weekly or monthly treatment per the product schedule",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 Standard Precautions",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 Standard Precautions"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "daily",
      "id": "cict-010",
      "kind": "clinical",
      "materials": [
        "suction line cleaner/evacuation system cleaner",
        "PPE (gloves, mask, eye protection)",
        "replacement solids collector/trap",
        "biohazard bag"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Assistant puts on gloves, mask and eye protection before disconnecting or flushing any suction line component.\n\nWhy: Suction lines carry blood, saliva and aerosol contaminants; standard precautions apply to every line, every patient.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Don PPE before handling suction lines",
          "why": "Suction lines carry blood, saliva and aerosol contaminants; standard precautions apply to every line, every patient."
        },
        {
          "detail": "At the end of the day, draw the recommended volume of evacuation-system cleaner through each suction line per the product label, running water through afterward.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Run suction line cleaner through the high-volume and saliva ejector lines"
        },
        {
          "detail": "Check hose connections for cracks or looseness and check the central or chairside filter/trap for visible buildup before closing up.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Inspect line connections and filters"
        },
        {
          "detail": "Initial the operatory's end-of-day checklist confirming suction lines were cleaned.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Log end-of-day suction cleaning"
        },
        {
          "detail": "Is today the scheduled weekly trap-change day?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "Yes — trap change is due"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "no",
              "label": "No — not due this shift"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Is today the scheduled weekly trap-change day?"
        },
        {
          "detail": "With PPE on, remove the trap, empty solid waste into a biohazard bag, and rinse the trap housing before reinstalling a clean trap or the same trap cleaned per manufacturer instructions.\n\nWhy: A clogged trap reduces suction power and can push contaminated debris back toward the patient's mouth.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Remove and empty the solids collector/trap",
          "why": "A clogged trap reduces suction power and can push contaminated debris back toward the patient's mouth."
        },
        {
          "detail": "Seal the biohazard bag and place it in the designated regulated-waste container per the practice's sharps/biohazard waste plan.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Dispose of trap waste as regulated medical waste"
        },
        {
          "detail": "Record the trap-change date and staff initials on the equipment maintenance log.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Log the weekly trap change"
        },
        {
          "detail": "Suction maintenance complete",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Suction maintenance complete"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Suction line cleaning and trap change — End of every day (lines) and weekly (traps).",
      "title": "Suction line cleaning and trap change",
      "trigger": "End of every day (lines) and weekly (traps)",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.3 Surface Disinfection, §1.4 Waterlines",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.3 Surface Disinfection, §1.4 Waterlines"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "daily",
      "id": "cict-011",
      "kind": "clinical",
      "materials": [
        "surface disinfectant",
        "PPE",
        "regulated-waste and sharps containers",
        "waterline log sheet",
        "equipment checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Run water through handpiece lines and the air/water syringe for 20-30 seconds before shutting the unit down.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Flush waterlines for end-of-day"
        },
        {
          "detail": "Draw evacuation-system cleaner through the high-volume and saliva ejector lines per the product label.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Run suction line cleaner"
        },
        {
          "detail": "Discard surface barriers, remove and safely dispose of any sharps into the sharps container, and bag regulated waste for disposal.\n\nWhy: Sharps and contaminated barriers left overnight are an exposure risk to the first person in the room the next morning.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Remove and dispose of single-use barriers and sharps",
          "why": "Sharps and contaminated barriers left overnight are an exposure risk to the first person in the room the next morning."
        },
        {
          "detail": "Clean then disinfect the dental chair, light handles, bracket tray, counters and touch surfaces using an EPA-registered hospital disinfectant, following the contact time on the label.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Wipe down and disinfect all operatory surfaces"
        },
        {
          "detail": "Turn off the operatory light, curing light, handpiece motor/compressor draw if applicable, and any monitors or accessory equipment not needed overnight.\n\nWhy: Reduces fire and electrical risk and extends equipment life; some equipment (e.g. central compressor) may stay on per manufacturer guidance — confirm the manual before shutting off shared systems.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Power down equipment",
          "why": "Reduces fire and electrical risk and extends equipment life; some equipment (e.g. central compressor) may stay on per manufacturer guidance — confirm the manual before shutting off shared systems."
        },
        {
          "detail": "Check and refill gloves, masks, cotton rolls, barrier film and other single-use consumables so the room is ready at open.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Restock consumables for the next day"
        },
        {
          "detail": "Assistant or hygienist initials the shutdown checklist confirming every step was completed for the room.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Sign off the end-of-day operatory checklist"
        },
        {
          "detail": "Operatory shutdown complete",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Operatory shutdown complete"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "End-of-day operatory shutdown — line flush, suction cleaner, equipment off, waste — The last patient in the room is dismissed.",
      "title": "End-of-day operatory shutdown — line flush, suction cleaner, equipment off, waste",
      "trigger": "The last patient in the room is dismissed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "cict-012",
      "kind": "clinical",
      "materials": [
        "spill kit (absorbent, gloves, gown, EPA-registered disinfectant)",
        "biohazard bags",
        "eye protection",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pause the procedure if one is in progress, and put on gloves, gown and eye protection from the spill kit before approaching the spill.\n\nWhy: Blood and saliva can transmit bloodborne pathogens; PPE goes on before contact, not after.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Stop work and don spill PPE",
          "why": "Blood and saliva can transmit bloodborne pathogens; PPE goes on before contact, not after."
        },
        {
          "detail": "Is a patient or staff member injured or exposed (e.g. splash to eye/mucous membrane, needlestick)?",
          "forks": [
            {
              "advised": false,
              "goto": "s10",
              "id": "yes",
              "label": "Yes — a person was exposed or injured"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "no",
              "label": "No — spill only, no exposure"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Is a patient or staff member injured or exposed (e.g. splash to eye/mucous membrane, needlestick)?"
        },
        {
          "detail": "Cover the spill with absorbent material from the spill kit, working from the outer edge inward to prevent spreading.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Contain and absorb the spill"
        },
        {
          "detail": "Pick up the saturated absorbent material and any visibly contaminated disposable items and place them in a biohazard bag.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Remove and discard contaminated absorbent material"
        },
        {
          "detail": "Apply an EPA-registered hospital disinfectant effective against bloodborne pathogens to the entire contaminated area and hold the manufacturer's stated contact (wet) time.\n\nWhy: Wiping without the full contact time leaves viable pathogens on the surface.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the affected surface",
          "why": "Wiping without the full contact time leaves viable pathogens on the surface."
        },
        {
          "detail": "Wipe the surface with a clean cloth or towel and place all remaining contaminated materials in the biohazard bag for regulated-waste disposal.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Wipe the surface dry and dispose of remaining waste"
        },
        {
          "detail": "Confirm no visible residue remains, the floor is dry (slip hazard), and all spill-kit PPE has been removed and disposed of or laundered per policy.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Verify the room before returning it to use"
        },
        {
          "detail": "Record the date, time, location, what was spilled, and cleanup steps taken in the incident log.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Log the spill event"
        },
        {
          "detail": "Room cleared for reuse",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Room cleared for reuse"
        },
        {
          "detail": "Hand this off immediately to the office's bloodborne-pathogen exposure-incident protocol for first aid, reporting and post-exposure evaluation; do not continue this cleanup protocol until the exposed person has been addressed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route to the exposure-incident protocol.",
            "role": "office-manager or practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "assistant",
          "title": "Route to the exposure-incident protocol"
        },
        {
          "detail": "Assistant hands the exposure details to the office manager to initiate the OSHA-required exposure-incident report and post-exposure evaluation offer.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to exposure-incident documentation"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Blood or body-fluid spill or gross contamination in the operatory — More than a few drops of blood or saliva-blood mixture is observed on the floor, counter or equipment.",
      "title": "Blood or body-fluid spill or gross contamination in the operatory",
      "trigger": "More than a few drops of blood or saliva-blood mixture is observed on the floor, counter or equipment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1 (in-repo generic checklist basis — no single public-domain source publishes a chairside daily checklist; this reflects generic dental-office operating practice built on the class's public infection-control floor)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1 (in-repo generic checklist basis — no single public-domain source publishes a chairside daily checklist; this reflects generic dental-office operating practice built on the class's public infection-control floor)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-shift",
      "id": "cict-013",
      "kind": "clinical",
      "materials": [
        "daily checklist form (paper or digital)",
        "operatory supply par lists"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm operatories are stocked and stripped/barriered, waterlines flushed, equipment powers on and functions, schedule reviewed for the day's procedure mix, and PPE supply is adequate.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Start-of-shift checklist"
        },
        {
          "detail": "Are any start-of-shift items missing or not working?",
          "forks": [
            {
              "advised": false,
              "goto": "s7",
              "id": "yes",
              "label": "Yes — shortage or equipment issue found"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "no",
              "label": "No — room ready"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Are any start-of-shift items missing or not working?"
        },
        {
          "detail": "Confirm turnover time targets are being met between patients, sharps/biohazard containers are not over the fill line, and supply pars are holding for the rest of the day's schedule.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Mid-shift checklist"
        },
        {
          "detail": "Confirm end-of-day operatory shutdown was completed for every room used, tomorrow's tray setups are pulled if the practice preps ahead, and any incidents or shortages from the day are logged.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "End-of-shift checklist"
        },
        {
          "detail": "Assistant initials and dates the completed checklist form and files or submits it per the practice's recordkeeping process.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Sign off the daily checklist"
        },
        {
          "detail": "Daily checklist complete",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Daily checklist complete"
        },
        {
          "detail": "Assistant reports the missing item or malfunction to whoever holds ordering/repair authority for the practice that day, before the first patient is seated.\n\nWhy: A shortage caught before the patient sits down is a five-minute fix; one discovered mid-procedure is a delay and a patient-experience hit.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Report the shortage or equipment issue",
          "why": "A shortage caught before the patient sits down is a five-minute fix; one discovered mid-procedure is a delay and a patient-experience hit."
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Assistant daily checklist (start, mid-shift, end of shift) — Every shift.",
      "title": "Assistant daily checklist (start, mid-shift, end of shift)",
      "trigger": "Every shift",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1 (generic four-handed dentistry technique — widely taught ergonomic practice, not a single public-domain publication, framed on the class's public infection-control floor)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1 (generic four-handed dentistry technique — widely taught ergonomic practice, not a single public-domain publication, framed on the class's public infection-control floor)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 0,
      "frequency": "per-use",
      "id": "cict-014",
      "kind": "clinical",
      "materials": [
        "procedure tray/cassette",
        "high-volume evacuator tip",
        "air/water syringe tip",
        "gauze",
        "mouth mirror"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Assistant positions the instrument tray and transfer zone within the standard clock-position reach envelope agreed with the dentist, so instruments pass below the patient's chin and out of their sight line.\n\nWhy: A consistent transfer zone lets the dentist keep eyes on the field instead of looking up to find the next instrument.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Set up the transfer zone",
          "why": "A consistent transfer zone lets the dentist keep eyes on the field instead of looking up to find the next instrument."
        },
        {
          "detail": "Assistant keeps the high-volume evacuator positioned for aerosol and fluid control and retracts cheek/tongue as needed, adjusting continuously as the dentist's working position changes.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Maintain suction and retraction during the procedure"
        },
        {
          "detail": "Assistant picks up the next instrument in the sequence and delivers it to the dentist's hand in the transfer zone using a single fluid motion, retrieving the used instrument at the same time.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Transfer instruments using a parallel or pen-grasp exchange"
        },
        {
          "detail": "Assistant wipes debris from instrument tips with gauze between uses and clears the mirror or field of view as needed without being asked.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Keep the working field clear"
        },
        {
          "detail": "Does the dentist need an instrument that is not on the current tray sequence?",
          "forks": [
            {
              "advised": false,
              "goto": "s8",
              "id": "yes",
              "label": "Yes — unplanned instrument needed"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "no",
              "label": "No — sequence continues as planned"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Does the dentist need an instrument that is not on the current tray sequence?"
        },
        {
          "detail": "Assistant tracks the procedure's known sequence (e.g. from the tray setup card) and has the next instrument ready before it is requested.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Anticipate the next step in the procedure sequence"
        },
        {
          "detail": "Transfer sequence continues through procedure completion",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Transfer sequence continues through procedure completion"
        },
        {
          "detail": "Assistant retrieves the needed instrument from the setup cart or a second tray while maintaining suction/retraction continuity, or briefly hands off suction to complete the retrieval.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Retrieve the unplanned instrument without breaking the field"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Four-handed instrument transfer and field maintenance — Throughout any operative procedure.",
      "title": "Four-handed instrument transfer and field maintenance",
      "trigger": "Throughout any operative procedure",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Business and Professions Code §§1750–1777 (Dental Practice Act — registered dental assistant/hygienist scope and supervision levels)",
          "source": "California Business and Professions Code §§1750–1777 (Dental Practice Act — registered dental assistant/hygienist scope and supervision levels)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California minimum standards for infection control and delegated duties (16 CCR)",
          "source": "Dental Board of California minimum standards for infection control and delegated duties (16 CCR)",
          "url": "https://www.dbc.ca.gov/"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "cict-015",
      "kind": "clinical",
      "materials": [
        "state dental practice act scope-of-practice reference",
        "staff competency/certification file",
        "supervision-level chart"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Dentist names the specific procedure or function to be delegated (e.g. coronal polishing, placing a sealant, taking an impression) and which staff member would perform it.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist identifies the task to delegate"
        },
        {
          "detail": "Confirm the named function is within the legal scope of practice for that staff member's license or registration type (assistant vs registered dental assistant vs expanded-function assistant vs hygienist) per the state dental practice act.\n\nWhy: Scope of practice is set by state statute, not by practice policy; performing an out-of-scope function is a licensure risk for both the delegator and the person performing it.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Check the task against the state practice act scope of practice",
          "why": "Scope of practice is set by state statute, not by practice policy; performing an out-of-scope function is a licensure risk for both the delegator and the person performing it."
        },
        {
          "detail": "Is the function within that staff member's legal scope of practice?",
          "forks": [
            {
              "advised": false,
              "goto": "s11",
              "id": "no",
              "label": "No — outside legal scope for this role"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — within legal scope"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "title": "Is the function within that staff member's legal scope of practice?"
        },
        {
          "detail": "Confirm what level of supervision the state requires for this function (e.g. direct supervision, indirect supervision, general supervision) and whether that level is currently met in the room.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Check the required supervision level"
        },
        {
          "detail": "Is the required supervision level currently met?",
          "forks": [
            {
              "advised": false,
              "goto": "s11",
              "id": "no",
              "label": "No — supervision requirement not currently met"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "Yes — supervision requirement met"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Is the required supervision level currently met?"
        },
        {
          "detail": "Check that the staff member's competency, certification or additional-function training documentation for this specific task is current and on file.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Verify competency documentation is on file"
        },
        {
          "detail": "Dentist confirms in the moment (verbally or via the delegation log) that scope, supervision and competency have all been checked before the staff member performs the task.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off before the delegated task proceeds.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off before the delegated task proceeds"
        },
        {
          "detail": "Dentist confirms the task, the patient, and the specific tooth or site with the assistant or hygienist before stepping away.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hand the task to the staff member"
        },
        {
          "detail": "Record the delegated task, staff member, date and supervision level in the delegation log or the patient's chart entry for the visit.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Log the delegation"
        },
        {
          "detail": "Delegation check complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Delegation check complete"
        },
        {
          "detail": "Dentist either performs the function directly or reassigns it to a staff member whose license/registration covers it.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Do not delegate; reassign or perform the task directly"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Expanded-function delegation check (state scope, supervision level, competency on file) — The dentist delegates a task to an assistant or hygienist.",
      "title": "Expanded-function delegation check (state scope, supervision level, competency on file)",
      "trigger": "The dentist delegates a task to an assistant or hygienist",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "— chairside dismissal/handoff, no applicable authority or in-repo section confirmed — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic functional equivalent — chairside dismissal/handoff, no applicable authority or in-repo section confirmed"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Direct read of DOCS/TECHNICAL_PROTOCOLS.md §8.1 (SOAP-format clinical note content: Subjective/Objective/Assessment/Plan) and §8.2 (informed-consent documentation requirements: diagnosis, proposed treatment, alternatives, material risks) confirms neither section mentions routing slips, checkout, or patient escort.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.1–8.2 (documentation standards — generic functional equivalent for the dismissal/handoff step, since no single public-domain source publishes a dismissal script)",
              "url": null
            }
          },
          "source": "— chairside dismissal/handoff, no applicable authority or in-repo section confirmed — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "cict-016",
      "kind": "clinical",
      "materials": [
        "routing slip (paper or digital)",
        "post-op instruction sheet (procedure-specific)",
        "next-visit reminder card"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Assistant confirms with the dentist that treatment is complete and there is no further chairside instruction needed before helping the patient up from the chair.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the patient is ready to be dismissed"
        },
        {
          "detail": "Does this procedure require written post-operative instructions?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "Yes — procedure has specific post-op guidance"
            },
            {
              "advised": false,
              "goto": "s4",
              "id": "no",
              "label": "No — routine visit, no special instructions"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Does this procedure require written post-operative instructions?"
        },
        {
          "detail": "Assistant hands the patient (or caregiver) the procedure-specific post-op instruction sheet and reviews the key points verbally, including when to call the office.\n\nWhy: Verbal review in addition to the printed sheet improves the chance the patient actually follows the instructions once home.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Give and review post-op instructions",
          "why": "Verbal review in addition to the printed sheet improves the chance the patient actually follows the instructions once home."
        },
        {
          "detail": "Fill in the treatment performed, any follow-up needed, next-visit recommendation, and the provider's initials on the routing slip.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Complete the routing slip"
        },
        {
          "detail": "Assistant walks the patient to the front desk (or confirms the patient can self-navigate for a low-mobility-risk routine visit) and hands the routing slip to front desk staff.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Escort the patient to checkout"
        },
        {
          "detail": "Front desk receives the routing slip and uses it to schedule the next visit and process checkout, including any payment or insurance follow-up.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off the routing slip to front desk"
        },
        {
          "detail": "Assistant notes the dismissal time on the day sheet or schedule so turnover timing for the next patient can begin.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Note dismissal time"
        },
        {
          "detail": "Patient dismissed and handed off to checkout",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Patient dismissed and handed off to checkout"
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Patient dismissal from the chair and escort to checkout with routing slip — The procedure is complete and the routing slip is filled.",
      "title": "Patient dismissal from the chair and escort to checkout with routing slip",
      "trigger": "The procedure is complete and the routing slip is filled",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.2 (Spaulding classification, sterile transfer handling) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md §1.2 (Spaulding classification, sterile transfer handling)"
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.2 (Spaulding classification, sterile transfer handling) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "cict-017",
      "kind": "clinical",
      "materials": [
        "backup instrument cassette or loose set",
        "sterile transfer tray or peel pouch",
        "sterile gloves for the runner",
        "sharps container"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "The chairside assistant scans the tray against the setup list for the procedure type and confirms an item the dentist is about to need is absent, damaged, or already used up.\n\nWhy: Catching the gap before the dentist reaches for the item avoids an unplanned hand movement into a non-sterile zone.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Notice the tray or supply is missing an item mid-procedure",
          "why": "Catching the gap before the dentist reaches for the item avoids an unplanned hand movement into a non-sterile zone."
        },
        {
          "detail": "Check the cabinet or a second cassette in the same operatory for a sterile equivalent that does not require leaving the room.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "substitute-in-room",
              "label": "Yes — a sterile substitute is in the room"
            },
            {
              "advised": false,
              "goto": "s6",
              "id": "no-substitute",
              "label": "No — the item must come from central sterilization or storage"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Is there an acceptable sterile substitute already in the room?"
        },
        {
          "detail": "Open the substitute item's sterile packaging away from the tray, present it into the dentist's hand or the sterile field without contaminating either, and continue the procedure.\n\nWhy: A substitute only solves the shortage if it is delivered without breaking the sterile field it is meant to preserve.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Present the sterile substitute using standard transfer technique",
          "why": "A substitute only solves the shortage if it is delivered without breaking the sterile field it is meant to preserve."
        },
        {
          "detail": "After the patient is dismissed, note the item, the procedure type, and whether it was a stock-out or a setup miss on the daily supply log so the office manager can adjust par levels or the setup checklist.\n\nRecord: Item name, procedure type, cause (stock-out vs. setup miss), and date are logged on the supply/shortage tracking sheet.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Log the shortage for restock and setup-checklist review"
        },
        {
          "detail": "Procedure resumed with sterile supply in place; shortage logged",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Procedure resumed with sterile supply in place; shortage logged"
        },
        {
          "detail": "State clearly what is missing and how long retrieval will take (e.g. \"we're out of X, [runner] is getting a sterile one now, about two minutes\") so the dentist can decide whether to pause, work on another quadrant, or wait.\n\nWhy: A silent gap reads as hesitation to the dentist and the patient; naming the delay keeps the room calm and lets the dentist manage chair time.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Notify the dentist of the delay and the plan to resolve it",
          "why": "A silent gap reads as hesitation to the dentist and the patient; naming the delay keeps the room calm and lets the dentist manage chair time."
        },
        {
          "detail": "If a second assistant or the sterilization technician is available, they retrieve the item so the chairside assistant never leaves the dentist without support.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "second-staff-runs",
              "label": "A second staff member retrieves the item"
            },
            {
              "advised": false,
              "goto": "s8",
              "id": "chairside-must-leave",
              "label": "No second staff available — chairside assistant must step out briefly"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "assistant",
          "title": "Who leaves the chairside position to retrieve the item?"
        },
        {
          "detail": "Pull a sterile, in-date replacement item (cassette, pouch, or loose instrument) and carry it to the operatory in its unopened sterile packaging.\n\nWhy: Only a still-sealed sterile package can re-enter the field without a new disinfection step.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Retrieve a sterile replacement from central sterilization or stock",
          "why": "Only a still-sealed sterile package can re-enter the field without a new disinfection step."
        },
        {
          "detail": "Check: did the retrieving person touch door handles, drawer pulls, or other non-sterile surfaces after gloving; if yes, re-glove before handling the sterile item near the field; if the item's own packaging stayed sealed throughout, no re-glove is needed to hand it off unopened.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Regown before re-entering the sterile field if gloves were touched to non-sterile surfaces"
        },
        {
          "detail": "Peel or unwrap the sterile package away from the tray and present the item directly into the dentist's hand or drop it onto the sterile field without the outer packaging touching the field.\n\nWhy: Aseptic transfer technique is what keeps the field sterile through a mid-procedure resupply.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Open and transfer the replacement item using standard aseptic transfer",
          "why": "Aseptic transfer technique is what keeps the field sterile through a mid-procedure resupply."
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Missing instrument or supply discovered mid-procedure — A needed item is not on the tray during treatment.",
      "title": "Missing instrument or supply discovered mid-procedure",
      "trigger": "A needed item is not on the tray during treatment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California — informed consent and right to refuse or withdraw from treatment (16 CCR; general consent doctrine)",
          "source": "Dental Board of California — informed consent and right to refuse or withdraw from treatment (16 CCR; general consent doctrine)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §8.3 (Refusal of Treatment documentation)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.3 (Refusal of Treatment documentation)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "cict-018",
      "kind": "clinical",
      "materials": [
        "stop signal agreed at consent (raised hand)",
        "water/rinse cup",
        "chart/consent record"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Watch for the pre-agreed stop signal (commonly a raised hand), visible panic (gagging, tears, gripping the chair), or a spoken request such as \"stop\" or \"wait.\" Alert the dentist immediately if the dentist has not already noticed.\n\nWhy: Patients under a rubber dam or with instruments in the mouth cannot always speak; an agreed non-verbal signal must be honored exactly like a verbal one.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Recognize the patient's distress signal or verbal request to stop",
          "why": "Patients under a rubber dam or with instruments in the mouth cannot always speak; an agreed non-verbal signal must be honored exactly like a verbal one."
        },
        {
          "detail": "Withdraw all instruments and the handpiece from the patient's mouth right away; do not finish \"just this last step\" first.\n\nWhy: Continuing even briefly after a stop signal is treatment without consent and escalates the patient's distress.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Stop the procedure immediately and remove instruments from the mouth",
          "why": "Continuing even briefly after a stop signal is treatment without consent and escalates the patient's distress."
        },
        {
          "detail": "The dentist personally confirms with the patient what they need right now (a short break, an explanation, or to stop the visit entirely) before proceeding in any direction.\n\nWhy: Only the licensed dentist can determine whether continuing after distress remains within the patient's consent, and this is not delegable to the assistant.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent checkpoint — confirm the patient's wishes before any further action.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent checkpoint — confirm the patient's wishes before any further action",
          "why": "Only the licensed dentist can determine whether continuing after distress remains within the patient's consent, and this is not delegable to the assistant."
        },
        {
          "detail": "Ask the patient directly what happened — pain not controlled by anesthesia, gag reflex, claustrophobia from the dam, dizziness, or general anxiety each point to a different next step.\n\nWhy: Pain and physical symptoms need a clinical fix (more anesthetic, dam adjustment, vitals check); anxiety alone needs reassurance and pacing, not more anesthetic.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Assess whether the cause is anxiety, pain, or a physical symptom",
          "why": "Pain and physical symptoms need a clinical fix (more anesthetic, dam adjustment, vitals check); anxiety alone needs reassurance and pacing, not more anesthetic."
        },
        {
          "detail": "Sort what the patient described: gagging, claustrophobia from the dam, or general anxiety with no physical complaint is one path; dizziness, chest pain, faintness, breathing difficulty, or possible allergic reaction is a different path that needs a vitals check before anything else.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "anxiety-only",
              "label": "Anxiety, gagging, or claustrophobia only — no physical/medical symptom reported"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "physical-symptom",
              "label": "Physical or medical symptom reported (dizziness, chest pain, faintness, breathing difficulty, possible allergic reaction)"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the cause anxiety alone, or a physical/medical symptom?"
        },
        {
          "detail": "Offer a real choice: a few minutes to recover with reassurance and, if appropriate, an anxiety-management option (nitrous, slower pacing, stop signals re-confirmed) versus ending the visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "continue-after-break",
              "label": "Patient agrees to continue after a short break and reassurance"
            },
            {
              "advised": false,
              "goto": "s13",
              "id": "patient-wants-to-stop",
              "label": "Patient wants to stop the procedure for today"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient want to continue after a short break, or stop for today?"
        },
        {
          "detail": "Raise the chair, offer water or a rinse, and give the patient a few quiet minutes; re-confirm the stop signal before instruments go back in.",
          "id": "s7",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 300,
          "title": "Give the patient a brief recovery break before resuming"
        },
        {
          "detail": "Re-explain each next step out loud before doing it, and re-confirm the stop signal is still active; proceed at the pace the patient set.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Resume treatment with the agreed pacing or anxiety-management plan"
        },
        {
          "detail": "Chart what was completed, the stated reason for stopping, whether the patient consented to resume same-visit or asked to reschedule, and any anxiety-management plan offered.\n\nRecord: Procedure stage at interruption, stated reason, resumption or reschedule decision, and any anxiety-management offer are documented in the clinical note.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the interruption, the reason, and the plan"
        },
        {
          "detail": "Patient's wishes honored and visit outcome fully documented",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Patient's wishes honored and visit outcome fully documented"
        },
        {
          "detail": "Recline the patient supine with legs elevated if presyncope is suspected, check pulse, breathing, and responsiveness, and ask about chest pain, breathing difficulty, or known allergen exposure. needs licensed-review note: this differential (anxiety vs. a physical/medical event) requires the treating dentist's own clinical judgment, not staff assumption.\n\nWhy: A physical or medical cause needs a clinical fix or emergency escalation, not the anxiety-management options offered further down this protocol; treating a medical event as anxiety delays real care.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Check vitals and position the patient before deciding anything else",
          "why": "A physical or medical cause needs a clinical fix or emergency escalation, not the anxiety-management options offered further down this protocol; treating a medical event as anxiety delays real care."
        },
        {
          "detail": "Weigh the checked vitals and symptom trend against the practice's medical-emergency criteria (see the medical-emergencies-at-the-chair protocol class, e.g. universal first response and syncope-in-the-chair).",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "stable-resume-path",
              "label": "Vitals normal and symptom resolving with positioning — safe to continue on the anxiety/pain pathway"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "emergency-signs",
              "label": "Signs of a medical emergency (chest pain, breathing difficulty, unresponsive, suspected anaphylaxis, or syncope that does not resolve with positioning)"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "dentist",
          "title": "Do the vitals or symptoms indicate a medical emergency?"
        },
        {
          "detail": "If a preparation or exposed dentin was left mid-procedure, the dentist places a temporary restoration or protective dressing before dismissal; discuss when the patient wants to reschedule.\n\nWhy: An unfinished procedure can leave a tooth vulnerable to sensitivity or contamination if nothing protects it until the next visit.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Stabilize any exposed tooth surface and dismiss the patient for today",
          "why": "An unfinished procedure can leave a tooth vulnerable to sensitivity or contamination if nothing protects it until the next visit."
        },
        {
          "detail": "Call 911/EMS immediately if the patient is unresponsive, not breathing normally, or in obvious severe distress. Activate the practice's medical-emergency-at-the-chair response (universal first response and, if syncope or anaphylaxis is suspected, the matching protocol in that class) before resuming or continuing any dental procedure.\n\nWhy: A physical/medical event that does not resolve with positioning is a 911-first event; this dental protocol is not the place to improvise emergency medical care.",
          "gate": {
            "ack": "I confirm I have completed this step as written: STOP — call 911 and hand off to the practice's medical-emergency response.",
            "type": "safety"
          },
          "id": "s14",
          "kind": "gate",
          "role": "dentist",
          "title": "STOP — call 911 and hand off to the practice's medical-emergency response",
          "why": "A physical/medical event that does not resolve with positioning is a 911-first event; this dental protocol is not the place to improvise emergency medical care."
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Patient becomes anxious, panics or asks to stop mid-procedure — A patient signals distress or withdraws consent during treatment.",
      "title": "Patient becomes anxious, panics or asks to stop mid-procedure",
      "trigger": "A patient signals distress or withdraws consent during treatment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.1, §1.2 (standard precautions, sterile gloves for surgical extractions/implant placement)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.1, §1.2 (standard precautions, sterile gloves for surgical extractions/implant placement)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "cict-019",
      "kind": "clinical",
      "materials": [
        "sterile surgical cassette",
        "sterile gloves (multiple sizes)",
        "sterile drapes/fenestrated drape",
        "sterile saline/irrigation",
        "surgical gown and mask with eye shield",
        "sterile instrument table cover"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Before any sterile field is opened, the dentist confirms the patient's identity, that signed surgical consent is on file, and the correct tooth or site against the treatment plan out loud with the team.\n\nWhy: A wrong-site or unconsented surgical procedure cannot be undone by good sterile technique — this check must happen before the field is committed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Pre-setup timeout — confirm patient identity, consent and surgical site.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Pre-setup timeout — confirm patient identity, consent and surgical site",
          "why": "A wrong-site or unconsented surgical procedure cannot be undone by good sterile technique — this check must happen before the field is committed."
        },
        {
          "detail": "Wipe down counters, light handles, and the instrument tray table with an EPA-registered intermediate-level disinfectant, then place fresh barriers on surfaces that will be touched during surgery.\n\nWhy: Sterile items placed on a contaminated surface are no longer sterile — the room must be clean first.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect and barrier all operatory surfaces before opening sterile supplies",
          "why": "Sterile items placed on a contaminated surface are no longer sterile — the room must be clean first."
        },
        {
          "detail": "Peel the sterilization pouch or wrap open at the edges only, keeping hands away from the inner sterile contents, and drop the cassette onto a sterile table cover.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Open the sterile surgical cassette onto a sterile field without contaminating it"
        },
        {
          "detail": "Wash hands and forearms with an antimicrobial scrub for the full recommended contact time, dry with a sterile towel, then don a surgical gown, mask, and full eye/face protection before gloving.\n\nWhy: Surgical hand antisepsis reduces resident and transient flora beyond routine hand hygiene, which matters once the sterile glove and surgical site are involved.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Perform surgical hand hygiene and don gown, mask and eye protection",
          "why": "Surgical hand antisepsis reduces resident and transient flora beyond routine hand hygiene, which matters once the sterile glove and surgical site are involved."
        },
        {
          "detail": "Check: outer glove wrapper opened by an assistant without the gloved hand touching the outside; gloves donned without the bare skin touching the glove's exterior surface; both gloves fully seated with no exposed skin at the cuff.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Don sterile gloves using closed-glove technique"
        },
        {
          "detail": "Place a fenestrated or towel drape so only the surgical field is exposed, securing edges so the drape does not slip during the procedure; avoid reaching over the sterile field with ungloved hands.\n\nWhy: Draping creates and maintains a visible boundary between sterile and non-sterile zones for the whole team.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Apply sterile draping around the surgical site",
          "why": "Draping creates and maintains a visible boundary between sterile and non-sterile zones for the whole team."
        },
        {
          "detail": "Visually confirm no glove tears, no drape has slipped off the field boundary, and no instrument has touched a non-sterile surface since setup began.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "field-intact",
              "label": "Yes — field is intact, proceed to surgery"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "field-compromised",
              "label": "No — a break is suspected"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the sterile field intact — no known breaks in gloves, drape, or instrument handling?"
        },
        {
          "detail": "Confirm out loud with the dentist that the field is ready and the correct instrument set is present before the dentist begins the incision or osteotomy.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the confirmed sterile field and instrument tray to the dentist to begin the procedure"
        },
        {
          "detail": "Note the sterilization lot/load number for the surgical cassette, the pre-incision timeout confirmation, and the time the sterile field was established in the surgical log or chart.\n\nRecord: Sterile cassette lot number, timeout confirmation, and field-establishment time are logged in the surgical/chart record.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Document the surgical asepsis setup"
        },
        {
          "detail": "Sterile surgical field established and verified; procedure may begin",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Sterile surgical field established and verified; procedure may begin"
        },
        {
          "detail": "Replace the torn glove, re-drape the affected area with fresh sterile drape, or swap the contaminated instrument for a fresh sterile one from a backup cassette before continuing.\n\nWhy: Any known break in sterile technique before incision must be corrected, not proceeded past, to avoid introducing infection risk.",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Re-establish the sterile field before surgery begins",
          "why": "Any known break in sterile technique before incision must be corrected, not proceeded past, to avoid introducing infection risk."
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Surgical asepsis setup — sterile field, sterile gloves, surgical draping — An implant, bone graft or surgical extraction is scheduled.",
      "title": "Surgical asepsis setup — sterile field, sterile gloves, surgical draping",
      "trigger": "An implant, bone graft or surgical extraction is scheduled",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — standard and transmission-based precautions",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — standard and transmission-based precautions",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Aerosol Transmissible Disease standard Title 8 §5199",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Aerosol Transmissible Disease standard Title 8 §5199",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 35,
      "frequency": "as-needed",
      "id": "cict-020",
      "kind": "clinical",
      "materials": [
        "N95 or higher respirator for airborne-precaution cases",
        "surgical masks for patient and staff",
        "isolation-capable operatory or end-of-day scheduling slot",
        "extra surface disinfectant and barriers"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "During check-in or a pre-visit call, note the patient's self-reported symptoms or diagnosis (e.g. active TB, flu-like illness, confirmed contagious infection) and flag the chart before the patient is seated.\n\nWhy: Catching this before seating, rather than after, is what makes precautions possible instead of reactive.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify that the patient has reported an active contagious condition",
          "why": "Catching this before seating, rather than after, is what makes precautions possible instead of reactive."
        },
        {
          "detail": "The dentist weighs urgency (pain, active infection needing drainage, emergency) against the risk of proceeding; routine or elective care is generally deferred until the patient is no longer contagious.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "defer",
              "label": "Defer — reschedule after the contagious period ends"
            },
            {
              "advised": false,
              "goto": "s6",
              "id": "must-treat",
              "label": "Must be seen today — urgent or emergency need"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Can the visit safely be deferred, or must the patient be seen today?"
        },
        {
          "detail": "Offer a new appointment after the typical contagious period for the reported condition, and advise the patient to call ahead if symptoms persist past that date.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Reschedule the visit and advise the patient on when to return"
        },
        {
          "detail": "Chart the patient's reported symptoms/diagnosis, the precaution tier applied (or the deferral decision), and any staff PPE used, without recording unnecessary clinical detail beyond what supports the precaution decision.\n\nRecord: Reported condition, precaution tier or deferral decision, and PPE used are documented in the chart.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Document the reported condition, precaution tier, and any deferral"
        },
        {
          "detail": "Visit completed (or deferred) with appropriate transmission-based precautions documented",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Visit completed (or deferred) with appropriate transmission-based precautions documented"
        },
        {
          "detail": "The dentist explicitly confirms the urgency justifies treating today under precautions rather than deferring the visit, before precautions are selected and the patient is brought back.\n\nWhy: Deciding to treat a known-contagious patient rather than defer carries exposure risk to staff and other patients, so it is a licensed clinical judgment call, not a scheduling default.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off to treat a contagious patient today rather than deferring.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off to treat a contagious patient today rather than deferring",
          "why": "Deciding to treat a known-contagious patient rather than defer carries exposure risk to staff and other patients, so it is a licensed clinical judgment call, not a scheduling default."
        },
        {
          "detail": "Determine whether the condition spreads by droplet (e.g. influenza-like illness) or airborne route (e.g. suspected active TB), which sets the PPE and room requirements.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "droplet",
              "label": "Droplet precautions — surgical mask for patient, standard room"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "airborne",
              "label": "Airborne precautions — N95/respirator, isolation-capable room if available"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Which transmission-based precaution tier applies?"
        },
        {
          "detail": "Check: patient given a surgical mask to wear in common areas and removed only during active treatment; staff wear standard PPE plus eye protection; patient scheduled for the last appointment of the day or a room with a closed door; extra distance maintained in the waiting area.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Apply droplet precautions"
        },
        {
          "detail": "Alert the assistant, hygienist, and dentist before the patient is escorted so everyone is in correct PPE before contact, and note the precaution tier on the schedule for the day.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify all staff who will contact the patient of the precaution tier in effect"
        },
        {
          "detail": "Limit the visit to the urgent problem, avoid elective aerosol-generating steps where possible, and keep the visit as short as safely achievable.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Provide only the urgent care needed, minimizing time and aerosol generation"
        },
        {
          "detail": "After the patient leaves, allow additional time beyond the standard turnover before the next patient enters, per the room's air-exchange rate, in addition to standard surface disinfection.\n\nWhy: Aerosol and droplet nuclei take time to clear from room air even after visible surfaces are disinfected.",
          "id": "s11",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 1200,
          "title": "Allow extended air-clearance time before the room is reused",
          "why": "Aerosol and droplet nuclei take time to clear from room air even after visible surfaces are disinfected."
        },
        {
          "detail": "Check: staff in the room wear a fit-tested N95 or higher respirator, not a surgical mask; patient placed directly into a private or isolation-capable room, bypassing the general waiting area; elective aerosol-generating procedures are deferred; only urgent care proceeds.\n\nWhy: Airborne pathogens require respiratory protection beyond a surgical mask and physical isolation from other patients, which a droplet-tier response does not provide.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Apply airborne precautions",
          "why": "Airborne pathogens require respiratory protection beyond a surgical mask and physical isolation from other patients, which a droplet-tier response does not provide."
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Patient with an active transmissible infection — standard plus transmission-based precautions — A patient reports active tuberculosis, influenza-like illness or another contagious condition and is still to be seen.",
      "title": "Patient with an active transmissible infection — standard plus transmission-based precautions",
      "trigger": "A patient reports active tuberculosis, influenza-like illness or another contagious condition and is still to be seen",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "No applicable regulatory authority for patient (as opposed to employee) eye protection — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No applicable regulatory authority for patient (as opposed to employee) eye protection — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "\"§ 1910.1030 Bloodborne pathogens. (a) Scope and Application. This section applies to all occupational exposure to blood or other potentially infectious materials...\" — the scope clause limits the rule to occupational (employee) exposure; it does not reach patient protective measures.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens; Cal/OSHA Title 8 §5193 — patient eye protection during procedures with splash/splatter risk",
              "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
            }
          },
          "source": "No applicable regulatory authority for patient (as opposed to employee) eye protection — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 (standard precautions, eye protection)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §1.1 (standard precautions, eye protection)"
        }
      ],
      "class": "chairside-assisting-operatory",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "cict-021",
      "kind": "clinical",
      "materials": [
        "patient protective eyewear (wraparound safety glasses)",
        "sterile eyewash or saline irrigation",
        "eye pad/shield if referral needed"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Before the dentist or hygienist begins any instrumentation, hand the patient wraparound protective eyewear and confirm it is seated comfortably and covers the eyes fully.\n\nWhy: Debris, irrigation splash, and aerosol from routine instrumentation can reach the eyes even in short or simple procedures.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Offer and fit patient protective eyewear before any procedure begins",
          "why": "Debris, irrigation splash, and aerosol from routine instrumentation can reach the eyes even in short or simple procedures."
        },
        {
          "detail": "Check: eyewear is on the patient's face, not pushed up or set aside; the patient can tolerate it (offer an alternate style if it presses on glasses or is uncomfortable); confirm before the dentist begins.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Verify eyewear is on and the patient is comfortable before starting"
        },
        {
          "detail": "Begin treatment only after eyewear placement is confirmed; if eyewear is removed or slips during treatment, pause briefly to reposition it.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with the procedure with eyewear confirmed in place"
        },
        {
          "detail": "Watch for the patient blinking excessively, tearing, or verbally reporting eye irritation or a foreign-body sensation.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-eye-report",
              "label": "No — procedure completed with no eye complaint"
            },
            {
              "advised": false,
              "goto": "s6",
              "id": "eye-report",
              "label": "Yes — patient reports debris or irritation in the eye"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the patient report something got in their eye during or after the procedure?"
        },
        {
          "detail": "Procedure completed with no eye incident",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Procedure completed with no eye incident"
        },
        {
          "detail": "Stop instrumentation, remove any instrument from near the patient's face, and ask the patient to describe what they feel (grittiness, burning, blurred vision) while visually checking the eye if the patient can tolerate it.\n\nWhy: A pause is needed both to protect the patient and to avoid introducing further debris while assessing.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Pause the procedure and assess the reported eye irritation",
          "why": "A pause is needed both to protect the patient and to avoid introducing further debris while assessing."
        },
        {
          "detail": "Have the patient tilt their head to the affected side and gently flush the eye with sterile eyewash or saline for several minutes, from the inner corner outward, while the patient blinks.\n\nWhy: Irrigation is the first and most effective step for removing loose debris and diluting any irritant before assuming a more serious injury.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Irrigate the affected eye with sterile eyewash or saline",
          "why": "Irrigation is the first and most effective step for removing loose debris and diluting any irritant before assuming a more serious injury."
        },
        {
          "detail": "Ask the patient whether the sensation has cleared; check for visible redness, embedded debris, or vision change that persists after irrigation.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "resolved",
              "label": "Resolved — irritation cleared after irrigation"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "not-resolved",
              "label": "Not resolved — persistent pain, embedded debris, or vision change"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Has irrigation resolved the irritation, or is further care needed?"
        },
        {
          "detail": "If the patient is comfortable and the procedure is not complete, refit protective eyewear and resume; otherwise conclude the visit as planned.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Resume the procedure if appropriate, or conclude the visit"
        },
        {
          "detail": "Chart what was reported, the irrigation performed, the outcome, and any referral given, so the incident is on record and available if the patient follows up.\n\nRecord: Reported symptom, irrigation performed, outcome, and any referral are documented in the chart.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the eye incident, response, and outcome"
        },
        {
          "detail": "Eye incident addressed and documented",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Eye incident addressed and documented"
        },
        {
          "detail": "Place a protective eye pad or shield if comfortable for the patient, advise them to seek prompt evaluation from an eye care provider or urgent care, and provide the reason for referral in writing if the patient requests it.\n\nWhy: Embedded debris, corneal abrasion, or a chemical irritant can require professional eye examination beyond what irrigation alone can resolve.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Cover the eye and refer the patient for prompt eye care",
          "why": "Embedded debris, corneal abrasion, or a chemical irritant can require professional eye examination beyond what irrigation alone can resolve."
        }
      ],
      "subclass": "operatory-setup-turnover-and-chairside-assisting",
      "summary": "Patient protective eyewear policy and debris-in-eye response — Any procedure begins, or a patient reports something in their eye after debris or splash.",
      "title": "Patient protective eyewear policy and debris-in-eye response",
      "trigger": "Any procedure begins, or a patient reports something in their eye after debris or splash",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.520 — Notice of Privacy Practices acknowledgment; 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "source": "HIPAA 45 CFR 164.520 — Notice of Privacy Practices acknowledgment; 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 — identity theft red flags at intake",
          "source": "FTC Red Flags Rule 16 CFR Part 681 — identity theft red flags at intake",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        },
        {
          "kind": "regulation",
          "label": "ADA Title III 28 CFR Part 36 — effective communication and accessible path at arrival",
          "source": "ADA Title III 28 CFR Part 36 — effective communication and accessible path at arrival",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "cio-001",
      "kind": "operational",
      "materials": [
        "sign-in sheet or check-in tablet",
        "photo ID scanner or copier",
        "insurance card scanner or copier",
        "Notice of Privacy Practices form",
        "new-patient forms (health history, financial policy)",
        "practice management system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Welcome the patient by name if known, confirm the appointment time and provider, and direct them to the check-in area.\n\nWhy: Confirming the appointment first avoids checking in the wrong patient or the wrong visit type.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Greet the new patient and confirm the scheduled appointment",
          "why": "Confirming the appointment first avoids checking in the wrong patient or the wrong visit type."
        },
        {
          "detail": "A minor patient typically has no government-issued photo ID and cannot legally sign consent, financial-policy or privacy-notice acknowledgments; a guardian must present ID and sign on the minor's behalf.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "adult",
              "label": "Patient is an adult"
            },
            {
              "goto": "s11",
              "id": "minor",
              "label": "Patient is a minor accompanied by a guardian"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the patient a minor?"
        },
        {
          "detail": "Ask for a driver's license, state ID or passport and the current insurance card; compare the name and date of birth to the appointment record.\n\nWhy: Verifying identity at the first visit catches a mismatched or borrowed identity before it enters the record (FTC Red Flags Rule 16 CFR Part 681).",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Request a government-issued photo ID and the insurance card",
          "why": "Verifying identity at the first visit catches a mismatched or borrowed identity before it enters the record (FTC Red Flags Rule 16 CFR Part 681)."
        },
        {
          "detail": "Does the ID and insurance card match the appointment record?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "match",
              "label": "Name and date of birth match"
            },
            {
              "goto": "s14",
              "id": "mismatch",
              "label": "Name, DOB or card details do not match, or the card looks altered"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the ID and insurance card match the appointment record?"
        },
        {
          "detail": "Collect or hand out the health history form, contact and emergency information, and the financial/consent policy acknowledgment.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Collect completed new-patient forms or provide them on a tablet or clipboard"
        },
        {
          "detail": "Save a legible front-and-back image or copy of the insurance card into the patient's record for benefits verification.\n\nWhy: A card image on file lets the front desk or billing re-check benefits without calling the patient back.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Scan or copy the insurance card, front and back",
          "why": "A card image on file lets the front desk or billing re-check benefits without calling the patient back."
        },
        {
          "detail": "Give the patient — or the accompanying guardian when the patient is a minor — the current Notice of Privacy Practices, answer questions, and obtain a signed or electronic acknowledgment before treatment begins.\n\nWhy: HIPAA 45 CFR 164.520 requires a good-faith effort to obtain acknowledgment at the first delivery of service; for a minor, the guardian executes the acknowledgment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Present the Notice of Privacy Practices and obtain acknowledgment.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "front-desk",
          "title": "Present the Notice of Privacy Practices and obtain acknowledgment",
          "why": "HIPAA 45 CFR 164.520 requires a good-faith effort to obtain acknowledgment at the first delivery of service; for a minor, the guardian executes the acknowledgment."
        },
        {
          "detail": "Note in the practice management system that forms were received, ID and insurance were verified, and the NPP acknowledgment was signed, with a timestamp.\n\nRecord: forms received, ID/insurance verified, NPP acknowledgment signed, check-in timestamp",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the completed check-in"
        },
        {
          "detail": "Update the patient status to checked-in in the practice management system so the assistant knows to seat the patient.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify the clinical team the patient is ready"
        },
        {
          "detail": "New patient checked in and ready to be seated",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "New patient checked in and ready to be seated"
        },
        {
          "detail": "Ask the accompanying adult for a driver's license, state ID or passport and confirm they are the parent, legal guardian, or another adult authorized to consent for this minor; compare the guardian's name to the appointment or custody record on file.\n\nWhy: A minor cannot execute consent, financial-policy or NPP-acknowledgment signatures, so the guardian's identity and authority to consent must be verified before any form is signed on the minor's behalf.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Request the guardian's photo ID and confirm the relationship to the minor patient",
          "why": "A minor cannot execute consent, financial-policy or NPP-acknowledgment signatures, so the guardian's identity and authority to consent must be verified before any form is signed on the minor's behalf."
        },
        {
          "detail": "Does the guardian's ID and stated relationship check out?",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "guardian-match",
              "label": "Guardian identity and authority to consent are confirmed"
            },
            {
              "goto": "s14",
              "id": "guardian-mismatch",
              "label": "Identity does not match, or authority to consent for this minor is unclear"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the guardian's ID and stated relationship check out?"
        },
        {
          "detail": "Collect or hand out the health history form, contact and emergency information, and the financial/consent policy acknowledgment for the guardian to complete and sign or initial on behalf of the minor patient.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Collect new-patient forms with the guardian signing on the minor's behalf"
        },
        {
          "detail": "Pause check-in and do not create or update the patient record; open the identity mismatch protocol (cio-003) instead.\n\nWhy: Continuing to check in a mismatched identity can attach one person's care to another person's record.",
          "id": "s14",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the identity red-flag protocol",
          "why": "Continuing to check in a mismatched identity can attach one person's care to another person's record."
        },
        {
          "detail": "Check-in paused pending identity resolution",
          "id": "s15",
          "kind": "step",
          "role": "front-desk",
          "title": "Check-in paused pending identity resolution"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "New patient check-in (forms, ID, insurance card, privacy notice) — A new patient arrives at the desk for a first visit.",
      "title": "New patient check-in (forms, ID, insurance card, privacy notice)",
      "trigger": "A new patient arrives at the desk for a first visit",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.520 — Notice of Privacy Practices acknowledgment; 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "source": "HIPAA 45 CFR 164.520 — Notice of Privacy Practices acknowledgment; 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 — identity theft red flags at intake",
          "source": "FTC Red Flags Rule 16 CFR Part 681 — identity theft red flags at intake",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 8,
      "frequency": "per-patient",
      "id": "cio-002",
      "kind": "operational",
      "materials": [
        "practice management system",
        "medical history update form",
        "insurance card scanner or copier"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "assistant",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the patient's name and date of birth and open their chart in the practice management system.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Greet the returning patient and pull up the existing record"
        },
        {
          "detail": "Ask whether address, phone, email or insurance carrier or plan has changed since the last visit.\n\nWhy: Stale contact or insurance information causes failed claims and missed reminders.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm contact information and insurance are current",
          "why": "Stale contact or insurance information causes failed claims and missed reminders."
        },
        {
          "detail": "Has anything changed since the last visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-change",
              "label": "Nothing has changed"
            },
            {
              "goto": "s10",
              "id": "changed",
              "label": "Contact info or insurance has changed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Has anything changed since the last visit?"
        },
        {
          "detail": "Ask about new diagnoses, new medications, allergies, hospitalizations, or pregnancy since the last visit, per the practice's history-update form.\n\nWhy: Medical history can change between visits and affects treatment decisions the dentist needs to know about before starting care.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Ask the standard medical history update questions",
          "why": "Medical history can change between visits and affects treatment decisions the dentist needs to know about before starting care."
        },
        {
          "detail": "Did the patient report any medical history changes?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-changes",
              "label": "No changes reported"
            },
            {
              "goto": "s11",
              "id": "changes-reported",
              "label": "New condition, medication or allergy reported"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the patient report any medical history changes?"
        },
        {
          "detail": "A minor cannot legally execute the history-form acknowledgment; a guardian initials on the minor's behalf.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "adult-initial",
              "label": "Patient is an adult"
            },
            {
              "goto": "s12",
              "id": "minor-initial",
              "label": "Patient is a minor accompanied by a guardian"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the patient a minor?"
        },
        {
          "detail": "Have the patient sign or initial the history form confirming it was reviewed today, whether or not anything changed.",
          "id": "s7",
          "kind": "step",
          "role": "patient",
          "title": "Patient initials the reviewed and updated history form"
        },
        {
          "detail": "Note in the record that demographics and history were reviewed, any changes made, and the initialed form is on file.\n\nRecord: demographics/insurance confirmed or updated, history reviewed and initialed, timestamp",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the completed check-in"
        },
        {
          "detail": "Returning patient checked in with current history on file",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Returning patient checked in with current history on file"
        },
        {
          "detail": "Enter the corrected phone, address, email or insurance details and rescan the insurance card if the plan changed.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Update contact and/or insurance information in the record"
        },
        {
          "detail": "Note the specific change on the routing slip or chart alert so the assistant and dentist see it before starting the visit.\n\nWhy: A new medication or allergy can change what is safe to do at this visit.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Flag the history change for the clinical team before treatment",
          "why": "A new medication or allergy can change what is safe to do at this visit."
        },
        {
          "detail": "Have the guardian sign or initial the history form on behalf of the minor patient, confirming it was reviewed today, whether or not anything changed.",
          "id": "s12",
          "kind": "step",
          "role": "caregiver",
          "title": "Guardian initials the reviewed and updated history form on behalf of the minor"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Existing patient check-in and medical history update — A returning patient arrives — contact, insurance and medical history confirmed or updated and initialed.",
      "title": "Existing patient check-in and medical history update",
      "trigger": "A returning patient arrives — contact, insurance and medical history confirmed or updated and initialed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 — identity theft red flags at intake",
          "source": "FTC Red Flags Rule 16 CFR Part 681 — identity theft red flags at intake",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.514 — minimum necessary and verification of identity before disclosure of protected health information",
          "source": "HIPAA 45 CFR 164.514 — minimum necessary and verification of identity before disclosure of protected health information",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "cio-003",
      "kind": "operational",
      "materials": [
        "FTC Red Flags Rule identity theft prevention program checklist",
        "secondary ID request script",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Stop the normal check-in flow; do not enter or change any information in the patient record until the discrepancy is resolved.\n\nWhy: Continuing to update a record under an uncertain identity can permanently mix two people's health information.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Pause check-in and do not create or update the record",
          "why": "Continuing to update a record under an uncertain identity can permanently mix two people's health information."
        },
        {
          "detail": "Away from other patients, ask for a second ID, the reason for a recent address change, or clarification on the mismatch, per the practice's Red Flags checklist.\n\nWhy: A calm, private follow-up resolves many innocent mismatches (a legal name change, a recently issued ID) without escalation.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Privately ask for a second form of ID or clarifying information",
          "why": "A calm, private follow-up resolves many innocent mismatches (a legal name change, a recently issued ID) without escalation."
        },
        {
          "detail": "Is the discrepancy resolved by the secondary information?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "resolved",
              "label": "Explanation and secondary ID are consistent and credible"
            },
            {
              "goto": "s9",
              "id": "unresolved",
              "label": "Still inconsistent, or the patient cannot produce a second ID"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the discrepancy resolved by the secondary information?"
        },
        {
          "detail": "The compliance officer reviews the flag and either clears the patient to proceed, requires further documentation before a future visit, or declines to proceed today.\n\nWhy: A named sign-off before any record action is the control the FTC Red Flags Rule program exists to enforce.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before the visit proceeds or the record is touched.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before the visit proceeds or the record is touched",
          "why": "A named sign-off before any record action is the control the FTC Red Flags Rule program exists to enforce."
        },
        {
          "detail": "What is the compliance decision?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "cleared",
              "label": "Cleared to proceed with normal check-in"
            },
            {
              "goto": "s7",
              "id": "declined",
              "label": "Declined for today — patient asked to return with documentation"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What is the compliance decision?"
        },
        {
          "detail": "Return to the new-patient or existing-patient check-in protocol now that the identity is confirmed.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Resume the appropriate check-in protocol"
        },
        {
          "detail": "Record what was flagged, the follow-up taken, who signed off, and the outcome in the incident log.\n\nRecord: red-flag description, follow-up documents seen, sign-off name, outcome (cleared or declined)",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the identity red-flag incident"
        },
        {
          "detail": "Identity red flag resolved and logged",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Identity red flag resolved and logged"
        },
        {
          "detail": "The office manager reviews the documents and the front desk's notes and decides whether to escalate further or decline to proceed today.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the office manager for a second review"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Identity mismatch or suspected medical identity theft at check-in — ID, insurance card and the existing record do not match, an address was recently changed by phone, or a card appears altered.",
      "title": "Identity mismatch or suspected medical identity theft at check-in",
      "trigger": "ID, insurance card and the existing record do not match, an address was recently changed by phone, or a card appears altered",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III 28 CFR Part 36 — effective communication and accessible path at arrival",
          "source": "ADA Title III 28 CFR Part 36 — effective communication and accessible path at arrival",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        },
        {
          "kind": "generic",
          "label": ": infection-control screening and isolation-at-arrival practice, drawn from standard office-based ambulatory infection-control precautions — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: infection-control screening and isolation-at-arrival practice, drawn from standard office-based ambulatory infection-control precautions — no vendor or consultancy program reproduced"
          },
          "source": ": infection-control screening and isolation-at-arrival practice, drawn from standard office-based ambulatory infection-control precautions — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "cio-004",
      "kind": "operational",
      "materials": [
        "arrival screening question script",
        "masks for patient and staff",
        "private waiting area or side entrance"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask whether the patient currently has a fever, cough, sore throat, rash or other symptoms of a contagious illness, per the practice's screening script.\n\nWhy: A brief screening question at arrival catches most contagious-illness cases before the patient enters shared waiting or treatment space.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Ask the standard arrival screening question",
          "why": "A brief screening question at arrival catches most contagious-illness cases before the patient enters shared waiting or treatment space."
        },
        {
          "detail": "Does the patient screen positive or appear visibly unwell?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "negative",
              "label": "No symptoms reported, patient appears well"
            },
            {
              "goto": "s5",
              "id": "positive",
              "label": "Symptoms reported or the patient appears acutely ill"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient screen positive or appear visibly unwell?"
        },
        {
          "detail": "Continue with the applicable new-patient or existing-patient check-in protocol.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Proceed with the normal check-in protocol"
        },
        {
          "detail": "Patient screened negative, normal check-in proceeded",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient screened negative, normal check-in proceeded"
        },
        {
          "detail": "Give the patient a mask if tolerated and seat them in a private area or ask them to wait in their vehicle if one is available, rather than the shared waiting room.\n\nWhy: Limiting exposure to other patients and staff while the dentist's decision is pending reduces the chance of spreading a contagious illness in the office.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer a mask and move the patient to a private area away from the general waiting room",
          "why": "Limiting exposure to other patients and staff while the dentist's decision is pending reduces the chance of spreading a contagious illness in the office."
        },
        {
          "detail": "The front desk relays the reported symptoms to the dentist, who decides whether to see the patient today with precautions, defer to a later time same day, or reschedule.\n\nWhy: Whether it is safe to treat despite reported symptoms is a clinical judgment call, not a front-desk decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews symptoms and decides whether to see, defer or reschedule.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews symptoms and decides whether to see, defer or reschedule",
          "why": "Whether it is safe to treat despite reported symptoms is a clinical judgment call, not a front-desk decision."
        },
        {
          "detail": "What did the dentist decide?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "see-today",
              "label": "See today with added precautions (mask, isolation operatory)"
            },
            {
              "goto": "s11",
              "id": "reschedule",
              "label": "Reschedule for after the illness resolves"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "What did the dentist decide?"
        },
        {
          "detail": "Skip the shared waiting room; seat the patient in the assigned operatory with masking and any additional precautions the dentist specified.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Seat the patient directly with precautions in place"
        },
        {
          "detail": "Record the reported symptoms, the dentist's decision, and the outcome (seen with precautions or rescheduled) in the chart.\n\nRecord: screening answers, dentist decision, outcome, timestamp",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the screen and the dentist's decision"
        },
        {
          "detail": "Positive screen resolved by dentist decision and documented",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Positive screen resolved by dentist decision and documented"
        },
        {
          "detail": "Rebook the appointment for after the illness resolves and give the patient general guidance on when it is appropriate to return, per practice policy.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Reschedule the appointment and give return-to-care guidance"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Patient arrives visibly ill, feverish or reports a contagious illness — The arrival screening question is positive or the patient appears acutely ill — see, defer or reschedule is decided by the dentist.",
      "title": "Patient arrives visibly ill, feverish or reports a contagious illness",
      "trigger": "The arrival screening question is positive or the patient appears acutely ill — see, defer or reschedule is decided by the dentist",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III 28 CFR Part 36 — effective communication with patients waiting for care",
          "source": "ADA Title III 28 CFR Part 36 — effective communication with patients waiting for care",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        },
        {
          "kind": "generic",
          "label": ": schedule-status check and proactive patient communication for a running-behind schedule — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: schedule-status check and proactive patient communication for a running-behind schedule — no vendor or consultancy program reproduced"
          },
          "source": ": schedule-status check and proactive patient communication for a running-behind schedule — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "cio-005",
      "kind": "operational",
      "materials": [
        "practice management system schedule view",
        "patient communication script for delays"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note the check-in time and monitor how long the patient has been waiting in reception.",
          "id": "s1",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 600,
          "title": "Track time from check-in to being seated"
        },
        {
          "detail": "Look at the schedule to see whether the provider is running behind on a prior patient, a room is not ready, or the wait is a scheduling gap.\n\nWhy: Knowing the cause determines what can honestly be told to the waiting patient.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Check the schedule for the cause of the delay",
          "why": "Knowing the cause determines what can honestly be told to the waiting patient."
        },
        {
          "detail": "What is causing the delay?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "provider-behind",
              "label": "Provider running behind on a prior patient"
            },
            {
              "goto": "s5",
              "id": "room-not-ready",
              "label": "Operatory or equipment not yet ready"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "What is causing the delay?"
        },
        {
          "detail": "Tell the patient the approximate additional wait and the reason, and check whether they would like water or a moment to step out.\n\nWhy: An unexplained wait feels longer and is a common driver of patient complaints even when the delay itself is short.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Proactively update the waiting patient",
          "why": "An unexplained wait feels longer and is a common driver of patient complaints even when the delay itself is short."
        },
        {
          "detail": "Let the assistant or provider know a patient has been waiting past the threshold so the room can be prioritized as soon as it is ready.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Notify the clinical team of the waiting patient"
        },
        {
          "detail": "Note the delay length and cause in the day's operations log so recurring delay patterns can be reviewed later.\n\nRecord: appointment time, seated time, delay length, cause",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the delay"
        },
        {
          "detail": "Delay communicated to the patient and logged",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Delay communicated to the patient and logged"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Waiting-room delay escalation — A checked-in patient has waited more than ten minutes past the appointment time.",
      "title": "Waiting-room delay escalation",
      "trigger": "A checked-in patient has waited more than ten minutes past the appointment time",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "source": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "per-shift",
      "id": "cio-006",
      "kind": "operational",
      "materials": [
        "privacy self-check checklist",
        "sign-in sheet template limited to name and time",
        "screen privacy filters"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm monitor screens are angled away from the waiting room, the sign-in sheet or tablet captures only name and arrival time (no reason for visit), and any prior day's printouts are cleared from the counter.\n\nWhy: A five-minute check before the first patient arrives prevents incidental disclosures for the whole shift.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Run the shift-opening privacy checklist",
          "why": "A five-minute check before the first patient arrives prevents incidental disclosures for the whole shift."
        },
        {
          "detail": "At shift huddle, remind staff to step to a private area or lower voices before discussing a balance, diagnosis or treatment plan with a patient at the counter.\n\nWhy: Balances and diagnoses spoken across an open counter are overheard by other patients more often than staff expect.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Remind the team to keep balance and diagnosis conversations private",
          "why": "Balances and diagnoses spoken across an open counter are overheard by other patients more often than staff expect."
        },
        {
          "detail": "Hand printed forms, receipts or chart pages directly to the patient or place them face-down in a designated tray, never left visible on the counter.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Route printed documents directly to the patient or a locked bin"
        },
        {
          "detail": "Is a compliance officer spot-check due this week?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "not-due",
              "label": "Not due this week"
            },
            {
              "goto": "s7",
              "id": "due",
              "label": "Spot-check is due"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is a compliance officer spot-check due this week?"
        },
        {
          "detail": "Initial the shift-opening privacy checklist and note any gap found and corrected.\n\nRecord: checklist completion, date/shift, any gap found and corrected",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the completed privacy checklist"
        },
        {
          "detail": "Shift-opening privacy checklist complete",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Shift-opening privacy checklist complete"
        },
        {
          "detail": "The compliance officer walks the front desk during a busy period and notes any screen, sign-in sheet or conversation privacy gap.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compliance officer performs the weekly spot-check"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Front-desk privacy practices (screens, sign-in sheet, conversations, printouts) — Every shift — screens angled, sign-in limited, balances and diagnoses never spoken across the counter.",
      "title": "Front-desk privacy practices (screens, sign-in sheet, conversations, printouts)",
      "trigger": "Every shift — screens angled, sign-in limited, balances and diagnoses never spoken across the counter",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "PCI DSS (open industry standard) — card-present and card-on-file handling",
          "source": "PCI DSS (open industry standard) — card-present and card-on-file handling",
          "url": "https://www.pcisecuritystandards.org/"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "cio-007",
      "kind": "operational",
      "materials": [
        "routing slip or chart note from the operatory",
        "practice management system",
        "payment terminal",
        "receipt printer or email receipt option"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Take the routing slip or chart note listing the procedures completed today and any next-visit recommendation.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive the routing slip from the operatory"
        },
        {
          "detail": "Check whether a recall, follow-up or treatment continuation appointment was recommended and at what interval.\n\nWhy: Booking the next visit before the patient leaves is the single biggest driver of recall compliance.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Review the next-visit recommendation",
          "why": "Booking the next visit before the patient leaves is the single biggest driver of recall compliance."
        },
        {
          "detail": "Offer available slots matching the recommended interval and book the appointment, adding it to the confirmation cascade.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Book the next appointment before the patient leaves the desk"
        },
        {
          "detail": "Check the estimated patient portion or any prior balance shown in the practice management system for today's visit.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Review the amount due today"
        },
        {
          "detail": "Is there a balance due today?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "balance-due",
              "label": "A payment is due today"
            },
            {
              "goto": "s7",
              "id": "no-balance",
              "label": "Nothing due today"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is there a balance due today?"
        },
        {
          "detail": "Follow the collect-estimated-portion-and-prior-balance protocol (cio-009) and the card handling protocol (cio-010) if a card is used.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Route to the payment collection protocol"
        },
        {
          "detail": "Print or email a receipt showing today's charges and payment, and give the patient the next appointment date and time in writing.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Give the patient a receipt and the next appointment card or confirmation"
        },
        {
          "detail": "Confirm the record shows the next appointment booked, payment status, and receipt delivered.\n\nRecord: next appointment date, payment status, receipt delivery method",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the completed checkout"
        },
        {
          "detail": "Patient checked out with next visit booked and payment resolved",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient checked out with next visit booked and payment resolved"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Standard checkout (next visit booked, payment, receipt) — A patient is dismissed from the operatory with a routing slip.",
      "title": "Standard checkout (next visit booked, payment, receipt)",
      "trigger": "A patient is dismissed from the operatory with a routing slip",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "PCI DSS (open industry standard) — card-present and card-on-file handling for any deposit collected",
          "source": "PCI DSS (open industry standard) — card-present and card-on-file handling for any deposit collected",
          "url": "https://www.pcisecuritystandards.org/"
        },
        {
          "kind": "generic",
          "label": ": treatment-plan presentation and consult-booking handoff between clinical and front-office staff — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: treatment-plan presentation and consult-booking handoff between clinical and front-office staff — no vendor or consultancy program reproduced"
          },
          "source": ": treatment-plan presentation and consult-booking handoff between clinical and front-office staff — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "cio-008",
      "kind": "operational",
      "materials": [
        "routing slip noting the new diagnosis",
        "treatment plan presentation materials",
        "financing/payment option information",
        "practice management system"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "treatment-coordinator",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Take the routing slip showing the newly diagnosed procedure, tooth or area, and any doctor notes on urgency.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive the routing slip noting new diagnosed treatment"
        },
        {
          "detail": "Walk the patient to the treatment coordinator's area and give the coordinator the diagnosis, doctor notes and any imaging referenced.\n\nWhy: Presenting a treatment plan is a distinct conversation from checkout logistics and works best away from the front counter.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off the patient and chart notes to the treatment coordinator",
          "why": "Presenting a treatment plan is a distinct conversation from checkout logistics and works best away from the front counter."
        },
        {
          "detail": "Can the plan be presented in full today?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "present-now",
              "label": "Coordinator is available and the plan is ready to present today"
            },
            {
              "goto": "s9",
              "id": "book-consult",
              "label": "Coordinator unavailable or the plan needs more workup"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "Can the plan be presented in full today?"
        },
        {
          "detail": "Walk the patient through the diagnosis, the recommended and alternative options, and the estimated cost with the practice's payment and financing options.\n\nWhy: A patient who understands the options and cost is more likely to accept and follow through.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the treatment plan, options and cost estimate",
          "why": "A patient who understands the options and cost is more likely to accept and follow through."
        },
        {
          "detail": "What did the patient decide?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "accepted",
              "label": "Patient accepts and wants to schedule treatment"
            },
            {
              "goto": "s7",
              "id": "thinking",
              "label": "Patient wants time to think or check financing"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "What did the patient decide?"
        },
        {
          "detail": "Send the accepted plan to the front desk to book the treatment appointment(s) per the plan's sequencing.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to schedule the accepted treatment"
        },
        {
          "detail": "Record what was presented, the patient's response (accepted, thinking it over, or consult booked), and any follow-up date.\n\nRecord: diagnosis presented, options discussed, cost estimate given, patient response, follow-up date",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the treatment-plan presentation outcome"
        },
        {
          "detail": "Treatment plan presented or consult booked, patient checked out",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Treatment plan presented or consult booked, patient checked out"
        },
        {
          "detail": "Schedule a follow-up consult visit specifically for presenting the plan, and give the patient any information to review beforehand.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Book a dedicated treatment-plan consult appointment"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Checkout with a new treatment plan (treatment coordinator handoff) — The doctor diagnosed new treatment during the visit and the patient must leave with a presentation or a consult booked.",
      "title": "Checkout with a new treatment plan (treatment coordinator handoff)",
      "trigger": "The doctor diagnosed new treatment during the visit and the patient must leave with a presentation or a consult booked",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "source": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) at the desk",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 6,
      "frequency": "per-patient",
      "id": "cio-009",
      "kind": "operational",
      "materials": [
        "ledger / PMS checkout screen",
        "card terminal",
        "printed or emailed receipt",
        "treatment-plan estimate on file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Before the patient reaches the counter, open the ledger and note (1) today's insurance-estimated patient portion and (2) any prior balance carried from earlier visits.\n\nWhy: Bundling both numbers before the conversation avoids surprising the patient with a second charge mid-transaction.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Pull today's estimate and any prior balance",
          "why": "Bundling both numbers before the conversation avoids surprising the patient with a second charge mid-transaction."
        },
        {
          "detail": "Tell the patient today's estimated portion and any prior balance as two clearly labeled numbers, out of earshot of the waiting room, before asking how they'd like to pay.\n\nWhy: Clear separation prevents the patient from disputing the total later as an unexplained lump sum, and keeps the amount off the open counter per HIPAA minimum-necessary practice.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "State the two amounts separately, in plain language",
          "why": "Clear separation prevents the patient from disputing the total later as an unexplained lump sum, and keeps the amount off the open counter per HIPAA minimum-necessary practice."
        },
        {
          "detail": "Check: benefits were verified for this visit; the insurance estimate matches what was quoted at treatment presentation; the prior-balance figure matches the ledger; any card on file is noted.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the estimate is still accurate"
        },
        {
          "detail": "How does the patient want to handle the balance today?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "pay-now",
              "label": "Pay the full amount today"
            },
            {
              "goto": "s8",
              "id": "dispute",
              "label": "Patient disputes the amount"
            },
            {
              "goto": "s10",
              "id": "cannot-pay",
              "label": "Patient cannot pay today"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "How does the patient want to handle the balance today?"
        },
        {
          "detail": "Run the card, cash, or check for the agreed amount using the terminal or ledger payment screen; apply it to the correct visit and any prior-balance line.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Process the payment"
        },
        {
          "detail": "Enter the amount collected, payment method, and any supervisor-approved adjustment in the ledger/PMS.\n\nRecord: Amount collected, payment method, and any supervisor-approved adjustment or plan terms; give the patient a receipt.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Record what was collected and any adjustment"
        },
        {
          "detail": "Checkout balance closed",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Checkout balance closed"
        },
        {
          "detail": "Pull the signed treatment-plan estimate and insurance EOB or benefits summary and show the patient how each line was calculated; correct the ledger if a genuine error is found.\n\nWhy: A visible, itemized walkthrough resolves most disputes at the desk instead of at collections.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Walk the patient through the charge line by line",
          "why": "A visible, itemized walkthrough resolves most disputes at the desk instead of at collections."
        },
        {
          "detail": "Is the amount now agreed?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "agreed",
              "label": "Patient agrees to pay"
            },
            {
              "goto": "s10",
              "id": "still-disputed",
              "label": "Still disputed — escalate"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the amount now agreed?"
        },
        {
          "detail": "Any payment plan, discount, or balance write-down beyond standard front-desk authority is approved by the office manager or practice owner before it is entered.\n\nWhy: Unsupervised balance adjustments at the desk are a common source of uncollected revenue and inconsistent patient treatment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor sign-off before a payment plan or balance adjustment.",
            "role": "office-manager or practice owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor sign-off before a payment plan or balance adjustment",
          "why": "Unsupervised balance adjustments at the desk are a common source of uncollected revenue and inconsistent patient treatment."
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Collecting the estimated patient portion or prior balance at checkout — The patient owes an estimated portion or carries a prior balance at time of service.",
      "title": "Collecting the estimated patient portion or prior balance at checkout",
      "trigger": "The patient owes an estimated portion or carries a prior balance at time of service",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "PCI DSS (open industry standard) — card-present and card-on-file handling",
          "source": "PCI DSS (open industry standard) — card-present and card-on-file handling",
          "url": "https://www.pcisecuritystandards.org/"
        },
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 — identity verification around payment",
          "source": "FTC Red Flags Rule 16 CFR Part 681 — identity verification around payment",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "cio-010",
      "kind": "operational",
      "materials": [
        "PCI-compliant card terminal",
        "card-on-file vault field in the PMS",
        "written card-on-file consent form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What kind of card payment is this?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "card-present",
              "label": "Card present at the counter"
            },
            {
              "goto": "s7",
              "id": "card-on-file",
              "label": "Store a card on file for future charges"
            },
            {
              "goto": "s9",
              "id": "phone-payment",
              "label": "Patient is paying by phone"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "What kind of card payment is this?"
        },
        {
          "detail": "Insert or tap the card on the PCI-compliant terminal; never key the full card number into the PMS or a paper form.\n\nWhy: Keeping the card number inside the certified terminal path is what keeps the office out of PCI scope for card data.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Run the card through the terminal",
          "why": "Keeping the card number inside the certified terminal path is what keeps the office out of PCI scope for card data."
        },
        {
          "detail": "Print or email a receipt showing only the last four digits of the card and the amount charged.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Give the patient a receipt"
        },
        {
          "detail": "Glance at the terminal for anything attached, loose, or swapped before returning it to its stand; report anything unusual per the tamper-inspection protocol (cio-011).\n\nWhy: A skimmer is most often noticed at the moment of use, not during the scheduled daily check.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the terminal looks untouched",
          "why": "A skimmer is most often noticed at the moment of use, not during the scheduled daily check."
        },
        {
          "detail": "Enter the transaction details in the ledger/PMS payment log right after the receipt is given.\n\nRecord: Amount, last four digits, payment type (card-present, card-on-file, phone), and staff initials.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the transaction"
        },
        {
          "detail": "Payment complete",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Payment complete"
        },
        {
          "detail": "Before vaulting a card for future charges, the patient signs a card-on-file consent form naming what future charges may be run against it (e.g. no-show fees, remaining balance after insurance) and how to revoke it.\n\nWhy: Storing a card without explicit, specific consent is both a PCI and a consumer-protection problem.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Written consent before storing a card.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "billing",
          "title": "Written consent before storing a card",
          "why": "Storing a card without explicit, specific consent is both a PCI and a consumer-protection problem."
        },
        {
          "detail": "Use the terminal's or processor's tokenization flow to store the card; the PMS keeps only the resulting token, never the card number.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Store the card through the vaulted terminal flow only"
        },
        {
          "detail": "Use the practice's phone-payment link or the terminal's manual-entry mode with the call on speaker for a second staff member to witness — never write the number down.\n\nWhy: A card number written on a sticky note or typed into chat is the single most common PCI violation at a front desk.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Take the phone payment through the approved channel only",
          "why": "A card number written on a sticky note or typed into chat is the single most common PCI violation at a front desk."
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Payment card handling (card-present, card-on-file, phone payments) — Any card payment, a phone payment, or a request to store a card for future charges — no card numbers on paper or in email.",
      "title": "Payment card handling (card-present, card-on-file, phone payments)",
      "trigger": "Any card payment, a phone payment, or a request to store a card for future charges — no card numbers on paper or in email",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "PCI DSS (open industry standard) — physical security of card-acceptance devices",
          "source": "PCI DSS (open industry standard) — physical security of card-acceptance devices",
          "url": "https://www.pcisecuritystandards.org/"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 4,
      "frequency": "daily",
      "id": "cio-011",
      "kind": "operational",
      "materials": [
        "card terminal serial-number log",
        "manufacturer tamper-evident seal reference photo",
        "flashlight"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check: terminal is in its usual location; serial number on the back matches the log; tamper-evident seal is intact and matches the reference photo; no extra device, cable, or overlay attached to the card slot or keypad; cables trace to the known connection with nothing spliced in.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Daily terminal inspection"
        },
        {
          "detail": "Was the terminal moved, serviced, or swapped since the last check?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-change",
              "label": "No — same terminal, same spot"
            },
            {
              "goto": "s6",
              "id": "changed",
              "label": "Yes — moved, serviced, or replaced"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was the terminal moved, serviced, or swapped since the last check?"
        },
        {
          "detail": "Does everything match?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean",
              "label": "Everything matches — clear to use"
            },
            {
              "goto": "s7",
              "id": "suspicious",
              "label": "Something doesn't match or looks altered"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does everything match?"
        },
        {
          "detail": "Initial and date the opening checklist log to confirm no tamper was found today.\n\nRecord: Date, initials, and 'no tamper found' in the opening checklist log.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the clean daily check"
        },
        {
          "detail": "Terminal check complete",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Terminal check complete"
        },
        {
          "detail": "Confirm the move or service ticket against records or a call to the processor/vendor's known support number (never a number left on a sticker at the terminal).\n\nWhy: A common attack swaps in a lookalike terminal claiming to be a scheduled service visit.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the change against a known work order",
          "why": "A common attack swaps in a lookalike terminal claiming to be a scheduled service visit."
        },
        {
          "detail": "Stop using the terminal immediately, take all patient payments by an alternate method, and notify the office manager and the card processor's fraud/security line before the terminal is touched again.\n\nWhy: Continuing to run cards through a suspected skimmer exposes every patient who pays that day.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Take the terminal out of service and escalate.",
            "role": "office-manager or compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "office-manager",
          "title": "Take the terminal out of service and escalate",
          "why": "Continuing to run cards through a suspected skimmer exposes every patient who pays that day."
        },
        {
          "detail": "Write up the suspected-tamper incident in the office's opening checklist log immediately.\n\nRecord: Date, description of what looked wrong, who was notified, and the processor's case number, if any.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the suspected tamper"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Payment terminal tamper and skimmer inspection — Opening checklist each day, or a terminal is moved or serviced.",
      "title": "Payment terminal tamper and skimmer inspection",
      "trigger": "Opening checklist each day, or a terminal is moved or serviced",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) when discussing the visit by phone or voicemail",
          "source": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) when discussing the visit by phone or voicemail",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "cio-012",
      "kind": "operational",
      "materials": [
        "day sheet / schedule",
        "patient contact information on file",
        "routing slip"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the waiting room, restroom, and parking area, and ask the operatory team when the patient was last seen, before treating this as a walkout.\n\nWhy: A patient stepping outside for a call is easy to mistake for a walkout and triggers an unnecessary callback.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the patient actually left",
          "why": "A patient stepping outside for a call is easy to mistake for a walkout and triggers an unnecessary callback."
        },
        {
          "detail": "Confirmed gone?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "still-here",
              "label": "Patient is still on site"
            },
            {
              "goto": "s4",
              "id": "gone",
              "label": "Confirmed the patient left the building"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Confirmed gone?"
        },
        {
          "detail": "Not a walkout — resume standard checkout",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Not a walkout — resume standard checkout"
        },
        {
          "detail": "Note any balance due, whether a next visit needs booking, and whether new treatment was diagnosed that still needs presenting.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Pull the routing slip and note what checkout still owes"
        },
        {
          "detail": "Call to check on them, note anything unpaid or unscheduled, and offer to handle checkout by phone (payment link, or booking the next visit) or at the start of the next visit.\n\nWhy: A prompt, friendly callback resolves most walkouts before they become an unpaid balance and preserves the relationship.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Call the patient the same day",
          "why": "A prompt, friendly callback resolves most walkouts before they become an unpaid balance and preserves the relationship."
        },
        {
          "detail": "Was the patient reached?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "reached",
              "label": "Reached — checkout completed by phone"
            },
            {
              "goto": "s9",
              "id": "not-reached",
              "label": "Not reached — leave a minimal-detail voicemail"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was the patient reached?"
        },
        {
          "detail": "Enter the walkout's outcome in the ledger/PMS so the next visit or billing pass sees the full picture.\n\nRecord: Date, what checkout item was missed, contact attempts made, and current status (resolved, pending recontact, sent to billing).",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Record the walkout and its status"
        },
        {
          "detail": "Walkout follow-up logged",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Walkout follow-up logged"
        },
        {
          "detail": "Leave a voicemail asking the patient to call the office back — never state a balance, diagnosis, or treatment detail in the message.\n\nWhy: A voicemail can be heard by anyone near the phone; balance and clinical detail are not minimum-necessary for a callback request.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Leave a callback request only",
          "why": "A voicemail can be heard by anyone near the phone; balance and clinical detail are not minimum-necessary for a callback request."
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Patient leaves without checking out — The operatory reports the patient gone and no checkout was completed.",
      "title": "Patient leaves without checking out",
      "trigger": "The operatory reports the patient gone and no checkout was completed",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) when discussing a found item or arranging its return by phone",
          "source": "HIPAA 45 CFR 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) + 164.514(d) (minimum necessary) when discussing a found item or arranging its return by phone",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "For lost-and-found custody — no vendor or consultancy system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for lost-and-found custody — no vendor or consultancy system reproduced"
          },
          "source": "For lost-and-found custody — no vendor or consultancy system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "cio-013",
      "kind": "operational",
      "materials": [
        "labeled lost-and-found bin or locked drawer",
        "lost-and-found log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Was the item found by staff or reported missing by the patient?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "found",
              "label": "Staff found an item"
            },
            {
              "goto": "s7",
              "id": "reported",
              "label": "Patient called to report something missing"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was the item found by staff or reported missing by the patient?"
        },
        {
          "detail": "Is the item medication?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "is-med",
              "label": "Yes — medication"
            },
            {
              "goto": "s4",
              "id": "not-med",
              "label": "No — other item"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the item medication?"
        },
        {
          "detail": "Place found medication in a locked drawer, not the open lost-and-found bin, and note the patient's name and time found only in the log — not the medication name, unless needed to arrange safe return.\n\nWhy: Loose medication left in an open bin is a safety and diversion risk.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Secure medication separately",
          "why": "Loose medication left in an open bin is a safety and diversion risk."
        },
        {
          "detail": "Write the found item into the lost-and-found log right away so it can be matched to a later report.\n\nRecord: Date, general description, where found, and holding location.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the item"
        },
        {
          "detail": "Call the patient to let them know the item is being held, and arrange pickup, mail-back, or return at their next visit.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the patient"
        },
        {
          "detail": "Lost-and-found handled",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Lost-and-found handled"
        },
        {
          "detail": "Check the chair, counter, waiting-room seating, and restroom for the reported item; ask the team who treated the patient that day.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Search the operatory, waiting room, and restroom"
        },
        {
          "detail": "Was the item found?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes-found",
              "label": "Found"
            },
            {
              "goto": "s9",
              "id": "not-found",
              "label": "Not found"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was the item found?"
        },
        {
          "detail": "Let the patient know which areas were searched and ask them to check back if it turns up; note the report so a later find can be matched to it.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Tell the patient what was checked"
        },
        {
          "detail": "Write the missing-item report into the lost-and-found log so a later find can be matched to it.\n\nRecord: Date, description, and areas searched.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the missing-item report"
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Patient leaves belongings, medication or valuables behind — Staff finds a phone, wallet, glasses or medication after a patient departs, or a patient reports an item missing.",
      "title": "Patient leaves belongings, medication or valuables behind",
      "trigger": "Staff finds a phone, wallet, glasses or medication after a patient departs, or a patient reports an item missing",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For front-desk child-safety supervision — no vendor or consultancy system reproduced; general duty-of-care practice for a place of business — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for front-desk child-safety supervision — no vendor or consultancy system reproduced; general duty-of-care practice for a place of business"
          },
          "source": "For front-desk child-safety supervision — no vendor or consultancy system reproduced; general duty-of-care practice for a place of business — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "ADA Title III 28 CFR Part 36 — accessible, safe path and area for anyone in the office, including accompanying minors",
          "source": "ADA Title III 28 CFR Part 36 — accessible, safe path and area for anyone in the office, including accompanying minors",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        },
        {
          "kind": "statute",
          "label": "California Penal Code §11165.7 et seq. (Child Abuse and Neglect Reporting Act) — dental and other health-care staff are mandated reporters of suspected child abuse or neglect",
          "source": "California Penal Code §11165.7 et seq. (Child Abuse and Neglect Reporting Act) — dental and other health-care staff are mandated reporters of suspected child abuse or neglect",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displayexpandedbranch.xhtml?tocCode=PEN&division=&title=&part=4.&chapter=2.&article=2.5."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "cio-014",
      "kind": "operational",
      "materials": [
        "sign-in sheet with guardian contact number",
        "quiet area or activity table if available"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "assistant",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "When a young child is seen alone in reception or is brought into the operatory during a parent's treatment, a staff member stays with or near the child right away rather than leaving them unsupervised while sorting it out.\n\nWhy: The immediate risk is an unsupervised young child in a clinical space with equipment and moving traffic, not the scheduling question.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Notice and approach the child calmly",
          "why": "The immediate risk is an unsupervised young child in a clinical space with equipment and moving traffic, not the scheduling question."
        },
        {
          "detail": "Check the sign-in sheet and the schedule to confirm which patient in treatment is the child's parent or guardian.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the guardian in treatment"
        },
        {
          "detail": "Is the child old enough to reasonably wait alone per office policy?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "too-young",
              "label": "Too young to wait unsupervised"
            },
            {
              "goto": "s8",
              "id": "old-enough",
              "label": "Old enough per office policy, just needs a check-in"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the child old enough to reasonably wait alone per office policy?"
        },
        {
          "detail": "Have a front-desk or assistant team member stay with the child at a quiet area within sight of the desk, or send word into the operatory so the guardian can decide whether to pause.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Arrange supervision or notify the treating team"
        },
        {
          "detail": "What does the guardian want to do?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "continue-with-supervision",
              "label": "Continue treatment, staff supervises the child"
            },
            {
              "goto": "s6",
              "id": "pause-treatment",
              "label": "Pause treatment to attend to the child"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "What does the guardian want to do?"
        },
        {
          "detail": "A staff member checks on or stays near the child at least every 10 minutes for as long as the guardian's treatment continues; total wait time tracks the length of the guardian's visit and can run well past this recheck interval, so treat this as a recurring check-in, not a one-time wait.",
          "id": "s6",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 600,
          "title": "Check on the child at a regular interval until the guardian is free"
        },
        {
          "detail": "Has supervision run unusually long or does anything feel wrong?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "normal",
              "label": "Normal length, nothing concerning"
            },
            {
              "goto": "s10",
              "id": "concerning",
              "label": "Unusually long, or something about the situation is concerning"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Has supervision run unusually long or does anything feel wrong?"
        },
        {
          "detail": "Write the event up in the day's incident notes before the shift ends.\n\nRecord: Date, child's approximate age, how long supervised, who supervised, and any escalation.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the event"
        },
        {
          "detail": "Child safely with guardian",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Child safely with guardian"
        },
        {
          "detail": "Bring the office manager or practice owner into the decision — whether to interrupt treatment, contact another emergency contact on file, or, when the situation meets the office's mandated-reporter threshold for suspected child abuse or neglect (California Penal Code §11165.7 et seq.), contact the reporting agency named in the practice's mandated-reporter policy.\n\nWhy: A prolonged or unusual unattended-child situation is a judgment call above front-desk authority — and dental staff are mandated reporters of suspected child abuse or neglect, so a genuine welfare concern here can trigger a legal reporting duty, not just an internal escalation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Involve a supervisor.",
            "role": "office-manager or practice owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "office-manager",
          "title": "Involve a supervisor",
          "why": "A prolonged or unusual unattended-child situation is a judgment call above front-desk authority — and dental staff are mandated reporters of suspected child abuse or neglect, so a genuine welfare concern here can trigger a legal reporting duty, not just an internal escalation."
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Unattended child or companion child in the waiting room or operatory — A parent is being treated and a young child is left alone in reception, or a sibling is brought into the operatory.",
      "title": "Unattended child or companion child in the waiting room or operatory",
      "trigger": "A parent is being treated and a young child is left alone in reception, or a sibling is brought into the operatory",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.520 — Notice of Privacy Practices; 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) — how a patient is addressed at the desk",
          "source": "HIPAA 45 CFR 164.520 — Notice of Privacy Practices; 164.502(a)(1)(iii) (incidental use/disclosure) + 164.530(c) (reasonable safeguards) — how a patient is addressed at the desk",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 — distinguishing a genuine name change from an identity mismatch",
          "source": "FTC Red Flags Rule 16 CFR Part 681 — distinguishing a genuine name change from an identity mismatch",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 6,
      "frequency": "as-needed",
      "id": "cio-015",
      "kind": "operational",
      "materials": [
        "chart demographics screen with a preferred-name field",
        "insurance card",
        "photo ID if required by the visit type"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "insurance-coordinator",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "What kind of mismatch is this?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "preferred-name-request",
              "label": "Patient asks to be addressed by a different name or pronouns"
            },
            {
              "goto": "s5",
              "id": "document-mismatch",
              "label": "Chart, ID and insurance card show different legal names"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "What kind of mismatch is this?"
        },
        {
          "detail": "Enter the patient's preferred name and pronouns in the chart's preferred-name field, and use it for how the patient is greeted and called back — while keeping the legal name intact for insurance and billing.\n\nWhy: Insurance claims and legal identity checks require the legal name on file; the preferred name governs how staff address the patient day to day, and the two can coexist without conflict.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Record the preferred name and pronouns",
          "why": "Insurance claims and legal identity checks require the legal name on file; the preferred name governs how staff address the patient day to day, and the two can coexist without conflict."
        },
        {
          "detail": "Log the resolution in the chart's demographics audit trail before the visit closes.\n\nRecord: What name/pronoun change was made or investigated, who made it, and any insurance-coordinator or compliance sign-off.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Record the resolution"
        },
        {
          "detail": "Name/identity mismatch resolved",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Name/identity mismatch resolved"
        },
        {
          "detail": "Compare the photo ID, insurance card, and chart name; ask whether this reflects a recent legal name change (marriage, divorce, gender transition, court order) versus a data-entry error.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify the legal identity match"
        },
        {
          "detail": "What explains the mismatch?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "legal-change",
              "label": "Genuine legal name change, documentation available"
            },
            {
              "goto": "s9",
              "id": "data-entry-error",
              "label": "Simple data-entry error in the chart"
            },
            {
              "goto": "s10",
              "id": "unclear",
              "label": "Unclear or documentation not available today"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "front-desk",
          "title": "What explains the mismatch?"
        },
        {
          "detail": "Update the chart's legal name field and flag the insurance-coordinator to confirm the new legal name matches what the carrier has on file before the next claim goes out.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Update the legal name across records"
        },
        {
          "detail": "Insurance coordinator confirms the carrier's name of record matches the updated chart before submitting or resubmitting any claim under the new name.",
          "id": "s8",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand off to the insurance coordinator"
        },
        {
          "detail": "Fix the data-entry error in the chart to match the patient's ID and insurance card.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Correct the chart directly"
        },
        {
          "detail": "When the mismatch cannot be explained as a routine legal change or a typo, hold any change to the record and involve the compliance officer before proceeding, since an unexplained name/identity mismatch is also the pattern the Red Flags Rule asks the office to watch for.\n\nWhy: An identity mismatch that isn't a clean legal-name change could indicate a genuine identity-theft red flag (cio-003), not just an inclusion or paperwork issue.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Flag an unresolved identity mismatch to compliance.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Flag an unresolved identity mismatch to compliance",
          "why": "An identity mismatch that isn't a clean legal-name change could indicate a genuine identity-theft red flag (cio-003), not just an inclusion or paperwork issue."
        }
      ],
      "subclass": "check-in-and-check-out",
      "summary": "Preferred name, pronouns or legal-name mismatch with insurance or prior records — A patient's chart, ID and insurance card show different names, or a patient asks to be addressed by a different name or pronouns.",
      "title": "Preferred name, pronouns or legal-name mismatch with insurance or prior records",
      "trigger": "A patient's chart, ID and insurance card show different names, or a patient asks to be addressed by a different name or pronouns",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "cpa-001",
      "kind": "compliance",
      "materials": [
        "designation memo template",
        "compliance binder",
        "org chart"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Owner confirms the practice must name one person as compliance officer and privacy/security official, responsible for the compliance program and for HIPAA privacy and security oversight.\n\nWhy: HIPAA administrative safeguards (45 CFR 164.308(a)(2)) require a covered entity to designate an official responsible for security policy, and OCR privacy guidance expects a named privacy official.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Identify the need for a designated official",
          "why": "HIPAA administrative safeguards (45 CFR 164.308(a)(2)) require a covered entity to designate an official responsible for security policy, and OCR privacy guidance expects a named privacy official."
        },
        {
          "detail": "Confirm the candidate has: authority to enforce policy across departments, no conflicting duty that would require self-policing, working knowledge of dental regulatory requirements, and protected time on the calendar for the role.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Candidate criteria checklist"
        },
        {
          "detail": "Select who takes the role",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "owner-serves",
              "label": "Practice owner serves as compliance officer"
            },
            {
              "goto": "s4",
              "id": "staff-designee",
              "label": "Designate a qualified staff member as compliance officer"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Select who takes the role"
        },
        {
          "detail": "Write the designation memo covering scope: policy manual maintenance, incident log ownership, staff training oversight, and point of contact for regulators and auditors.\n\nWhy: A written scope prevents the designation from being symbolic — the officer needs an enumerated mandate to act on.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the written designation and responsibilities",
          "why": "A written scope prevents the designation from being symbolic — the officer needs an enumerated mandate to act on."
        },
        {
          "detail": "The practice owner reviews and signs the designation memo before it takes effect, since it creates an ongoing legal responsibility for the named person.\n\nWhy: Formal designation shifts accountability; the owner who bears ultimate liability approves it before it is announced.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off on the designation.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off on the designation",
          "why": "Formal designation shifts accountability; the owner who bears ultimate liability approves it before it is announced."
        },
        {
          "detail": "Communicate the designation at a staff meeting or by email so every employee knows who to report concerns to.\n\nWhy: A compliance officer nobody knows about cannot receive reports.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Announce the designation to all staff",
          "why": "A compliance officer nobody knows about cannot receive reports."
        },
        {
          "detail": "Office manager transfers the policy manual, compliance calendar, incident log, and training matrix ownership to the designated compliance officer.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off compliance materials to the new officer"
        },
        {
          "detail": "File the signed designation memo in the compliance binder, update the org chart, and post the compliance officer's contact information where staff can see it.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record designation and post contact information"
        },
        {
          "detail": "Designation complete",
          "id": "s9",
          "kind": "step",
          "title": "Designation complete"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Designating the compliance officer and privacy/security official — The practice opens, the officer leaves, or a regulator asks who is responsible.",
      "title": "Designating the compliance officer and privacy/security official",
      "trigger": "The practice opens, the officer leaves, or a regulator asks who is responsible",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 180,
      "frequency": "annual",
      "id": "cpa-002",
      "kind": "compliance",
      "materials": [
        "compliance calendar tool",
        "prior-year calendar",
        "license/permit/insurance list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "List every license, permit, registration, insurance policy, required training, posting, and filing the practice must renew or repeat, with its current expiration or due date.\n\nWhy: The calendar is only as complete as the source list; missing one obligation is how lapses happen.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Gather every recurring compliance obligation",
          "why": "The calendar is only as complete as the source list; missing one obligation is how lapses happen."
        },
        {
          "detail": "Add a reminder date 90 days before each expiration so renewal work starts before the deadline, not on it.\n\nWhy: A 90-day buffer covers slow-moving state renewal processing and gives time to fix a rejected application.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Set a 90-day lead time on every renewal",
          "why": "A 90-day buffer covers slow-moving state renewal processing and gives time to fix a rejected application."
        },
        {
          "detail": "Enter every obligation, its owner, its due date, and its 90-day trigger date into the shared compliance calendar tool.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Build the shared calendar"
        },
        {
          "detail": "Confirm every calendar line has a named owner: office manager for postings/permits, compliance officer for HIPAA/OSHA items, practice owner for license and insurance renewals.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign an owner to each line item"
        },
        {
          "detail": "Practice owner reviews the completed calendar and confirms nothing is missing before it becomes the working document for the year.\n\nWhy: The owner carries final responsibility for license and insurance continuity, so the annual plan needs owner sign-off.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review before the calendar goes live.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review before the calendar goes live",
          "why": "The owner carries final responsibility for license and insurance continuity, so the annual plan needs owner sign-off."
        },
        {
          "detail": "Share the calendar with every named owner and post the current month's due items in the staff area.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Publish and distribute the calendar"
        },
        {
          "detail": "Each month, the compliance officer checks the calendar for items entering their 90-day window and starts the renewal task.",
          "id": "s7",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 1800,
          "title": "Monthly recurring check"
        },
        {
          "detail": "Record the completion date and new expiration date for each renewed item in the compliance calendar and the retention file.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log each renewal as it completes"
        },
        {
          "detail": "Calendar built and running",
          "id": "s9",
          "kind": "step",
          "title": "Calendar built and running"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Annual compliance calendar build — license, permit, registration and insurance renewals, trainings, tests, postings and filings — December planning, or a new obligation is added; each renewal is tracked 90 days ahead.",
      "title": "Annual compliance calendar build — license, permit, registration and insurance renewals, trainings, tests, postings and filings",
      "trigger": "December planning, or a new obligation is added; each renewal is tracked 90 days ahead",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "annual",
      "id": "cpa-003",
      "kind": "compliance",
      "materials": [
        "policy manual",
        "version history log",
        "acknowledgment tracker"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "practice-owner",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm whether this is the annual scheduled review, a policy change, or a request from an inspector for the current manual.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify what triggered the review"
        },
        {
          "detail": "Retrieve the policy manual's current version number, revision date, and change history from the version-controlled file.\n\nWhy: A manual without version control cannot prove to an inspector which policy was in force on a given date.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the current controlled version",
          "why": "A manual without version control cannot prove to an inspector which policy was in force on a given date."
        },
        {
          "detail": "Mark each section being added, revised, or removed, with the reason for the change noted next to it.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the proposed changes"
        },
        {
          "detail": "Office manager checks that the proposed wording matches how the front desk and clinical team actually work day to day.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Office manager reviews for operational fit"
        },
        {
          "detail": "Practice owner reviews and approves the updated manual before it is issued as the current version.\n\nWhy: The manual is the practice's stated policy; the owner approves it before staff are held to it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner approves the new version.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner approves the new version",
          "why": "The manual is the practice's stated policy; the owner approves it before staff are held to it."
        },
        {
          "detail": "Increment the version number, stamp the revision date, and archive the superseded version in the retention file.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Publish the new version number and date"
        },
        {
          "detail": "Every staff member reads the updated manual and signs or electronically acknowledges receipt of the current version.",
          "id": "s7",
          "kind": "step",
          "role": "all-staff",
          "title": "Collect staff acknowledgment"
        },
        {
          "detail": "Log each staff member's acknowledgment date in the training matrix; follow up with anyone outstanding.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Track acknowledgment completion"
        },
        {
          "detail": "Manual current and acknowledged",
          "id": "s9",
          "kind": "step",
          "title": "Manual current and acknowledged"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Policy and protocol manual version control, annual review and staff acknowledgment — A policy changes, the annual review date arrives, or an inspector asks for the current version.",
      "title": "Policy and protocol manual version control, annual review and staff acknowledgment",
      "trigger": "A policy changes, the annual review date arrives, or an inspector asks for the current version",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "cpa-004",
      "kind": "compliance",
      "materials": [
        "training matrix spreadsheet or system",
        "attestation forms",
        "training content library"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Determine whether this run is a new hire, an expiring training, the annual calendar roll, or a regulator request for training records.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify the trigger"
        },
        {
          "detail": "List required trainings per role: OSHA bloodborne pathogens for clinical staff, HIPAA privacy/security for all staff, harassment prevention for all staff, and emergency drill participation for all staff.\n\nWhy: Requirements differ by role, so a single flat checklist either over- or under-trains part of the team.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Build or update the training matrix by role",
          "why": "Requirements differ by role, so a single flat checklist either over- or under-trains part of the team."
        },
        {
          "detail": "For every employee, compare their last completion date against the required renewal interval and flag anyone due or overdue.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Check each employee against expiration dates"
        },
        {
          "detail": "How to deliver the training",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "group-session",
              "label": "Schedule a group session for everyone due at once"
            },
            {
              "goto": "s5",
              "id": "individual-makeup",
              "label": "Schedule individual make-up sessions"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "How to deliver the training"
        },
        {
          "detail": "Run the training session covering the required content for the role group, using current-year materials.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Deliver the training"
        },
        {
          "detail": "Each attendee signs or electronically attests completion, dated and tied to the specific training module delivered.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Collect signed attestation"
        },
        {
          "detail": "Enter the completion date into the training matrix and calculate the next renewal date for that employee and module.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the training matrix and set the next due date"
        },
        {
          "detail": "File attestations so the full training history for any employee can be produced within one business day of a request.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Keep records regulator-ready"
        },
        {
          "detail": "Training matrix current",
          "id": "s9",
          "kind": "step",
          "title": "Training matrix current"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Training matrix by role, annual required-training calendar (OSHA, HIPAA, harassment prevention, emergency drill) and attestation tracking — A new hire starts, a training expires, the annual calendar rolls, or a regulator requests training records.",
      "title": "Training matrix by role, annual required-training calendar (OSHA, HIPAA, harassment prevention, emergency drill) and attestation tracking",
      "trigger": "A new hire starts, a training expires, the annual calendar rolls, or a regulator requests training records",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "cpa-005",
      "kind": "compliance",
      "materials": [
        "incident log",
        "corrective action plan template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Record what happened, when, who was involved, and how it was discovered, in the compliance incident log within 24 hours.\n\nWhy: Contemporaneous detail is what makes a corrective action plan credible later, to an auditor or regulator.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Capture the incident as soon as it is known",
          "why": "Contemporaneous detail is what makes a corrective action plan credible later, to an auditor or regulator."
        },
        {
          "detail": "Classify the incident",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "near-miss",
              "label": "Near-miss or minor exposure with no likely harm"
            },
            {
              "goto": "s5",
              "id": "reportable",
              "label": "Privacy incident, exposure, or audit finding with possible reporting obligation"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Classify the incident"
        },
        {
          "detail": "Enter the near-miss in the incident log with a brief note on what will change to reduce recurrence.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the near-miss and note preventive follow-up"
        },
        {
          "detail": "Incident logged and closed",
          "id": "s4",
          "kind": "step",
          "title": "Incident logged and closed"
        },
        {
          "detail": "Brief the practice owner on the incident, its scope, and any known reporting obligations (breach notification, board contact, workers' comp).",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the practice owner"
        },
        {
          "detail": "Practice owner reviews the proposed corrective action plan and any reporting decision before it is finalized and executed.\n\nWhy: A corrective action plan with reporting implications carries legal and financial consequences the owner must own.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before the corrective action plan is finalized.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before the corrective action plan is finalized",
          "why": "A corrective action plan with reporting implications carries legal and financial consequences the owner must own."
        },
        {
          "detail": "Write the root cause, the specific corrective steps, who owns each step, and the target completion date.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the corrective action plan"
        },
        {
          "detail": "Hand each corrective action item to its named owner with the target date, and confirm they accept it.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign corrective actions to owners"
        },
        {
          "detail": "Compliance officer follows up daily until each corrective action's target date to confirm it was completed as written.",
          "id": "s9",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 86400,
          "title": "Verify completion by the target date"
        },
        {
          "detail": "Enter the closure date and verification note in the incident log; the record stays retained per the retention schedule.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the incident record"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Compliance incident log entry and corrective action plan — Any near-miss, exposure, privacy incident, board contact or audit finding occurs.",
      "title": "Compliance incident log entry and corrective action plan",
      "trigger": "Any near-miss, exposure, privacy incident, board contact or audit finding occurs",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "quarterly",
      "id": "cpa-006",
      "kind": "compliance",
      "materials": [
        "OSHA checklist",
        "HIPAA safeguards checklist",
        "state board inspection checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "sterilization-tech",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Compliance officer sets the date for the quarterly mock inspection, or moves it earlier if a real inspection window is known.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the mock audit"
        },
        {
          "detail": "Pull the current OSHA bloodborne-pathogen checklist, HIPAA administrative/physical/technical safeguards checklist, and the state dental board inspection checklist.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Select the walkthrough checklists"
        },
        {
          "detail": "Check sharps disposal, PPE availability, exposure control plan posting, eyewash station, and sterilization log completeness against the OSHA checklist.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Walk the OSHA items"
        },
        {
          "detail": "Check workstation screen privacy, document disposal (shredding), access log review, and posted notice of privacy practices against the HIPAA checklist.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Walk the HIPAA items"
        },
        {
          "detail": "Check posted licenses and permits, radiography safety signage, and controlled-substance storage against the state board checklist.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Walk the clinical/board items"
        },
        {
          "detail": "Rate each finding as pass, minor, or major, and rank major findings by how quickly they must be fixed.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Score and rank findings"
        },
        {
          "detail": "Compliance officer confirms the finding list is accurate and complete before it is turned into assigned corrective actions.\n\nWhy: A mock audit only improves readiness if its findings are acted on, not filed away.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review of findings before the corrective list is issued.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review of findings before the corrective list is issued",
          "why": "A mock audit only improves readiness if its findings are acted on, not filed away."
        },
        {
          "detail": "Assign each major or minor finding to a named owner with a fix-by date, feeding into the compliance incident log if the finding is significant.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Issue corrective items to owners"
        },
        {
          "detail": "File the completed checklists, scores, and corrective assignments with the date, ahead of the next quarterly cycle.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the mock audit results"
        },
        {
          "detail": "Mock audit complete",
          "id": "s10",
          "kind": "step",
          "title": "Mock audit complete"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Mock OSHA, HIPAA and board inspection walkthrough — Quarterly, or before a known inspection window.",
      "title": "Mock OSHA, HIPAA and board inspection walkthrough",
      "trigger": "Quarterly, or before a known inspection window",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "cpa-007",
      "kind": "compliance",
      "materials": [
        "retention schedule",
        "destruction log",
        "secure shredding/wipe method"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Compare record creation or last-activity dates against the retention schedule: HIPAA documentation 6 years, OSHA 300 logs 5 years, exposure records 30 years.\n\nWhy: Public retention floors (45 CFR 164.316 documentation; 29 CFR 1910.1030(h) exposure records) set the minimum; destroying earlier is a compliance risk.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify records reaching their retention period",
          "why": "Public retention floors (45 CFR 164.316 documentation; 29 CFR 1910.1030(h) exposure records) set the minimum; destroying earlier is a compliance risk."
        },
        {
          "detail": "Check for an active litigation hold",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-hold",
              "label": "No active hold on these records"
            },
            {
              "goto": "s8",
              "id": "active-hold",
              "label": "Records are under an active litigation hold"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Check for an active litigation hold"
        },
        {
          "detail": "List each eligible record by type, creation date, and retention basis, ready for review before disposal.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Prepare the destruction list"
        },
        {
          "detail": "Compliance officer confirms the destruction list is accurate and hold-free before any record is destroyed.\n\nWhy: Destruction cannot be undone; a second check before it happens is the only safeguard against destroying something still needed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sign-off before destruction.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Sign-off before destruction",
          "why": "Destruction cannot be undone; a second check before it happens is the only safeguard against destroying something still needed."
        },
        {
          "detail": "Shred paper records and securely wipe or destroy electronic media using a method appropriate to the record type.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Destroy the records securely"
        },
        {
          "detail": "Record what was destroyed, the retention basis, the destruction date, method, and who performed it, in the destruction log.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the destruction"
        },
        {
          "detail": "Retention cycle applied",
          "id": "s7",
          "kind": "step",
          "title": "Retention cycle applied"
        },
        {
          "detail": "Remove any record covered by an active litigation hold from the destruction list, regardless of retention age.\n\nWhy: A litigation hold overrides the normal retention schedule until it is lifted.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Exclude held records from this cycle",
          "why": "A litigation hold overrides the normal retention schedule until it is lifted."
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Compliance document retention schedule application and destruction log — Records reach their retention period (HIPAA documentation 6 years, OSHA 300 5 years, exposure records 30 years).",
      "title": "Compliance document retention schedule application and destruction log",
      "trigger": "Records reach their retention period (HIPAA documentation 6 years, OSHA 300 5 years, exposure records 30 years)",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "source": "HIPAA administrative safeguards 45 CFR 164.308 and documentation 164.316 (6-year retention); disclosures for judicial and law-enforcement purposes 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903",
          "source": "OSHA 29 CFR 1910.1030(h) recordkeeping and 1904 retention; OSHA inspection procedures 29 CFR 1903"
        },
        {
          "kind": "statute",
          "label": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Re-checked the three bundled authorities directly: CA B&P §801/§801.01 requires an insurer, not the practice, to report settlements/judgments above set thresholds to the licensing board — it creates no duty to designate a compliance officer or run mock inspections. CA Labor Code §3700 requires carrying workers'-comp insurance, nothing about policy manuals or training matrices. 28 CFR Part 36 (ADA Title III) governs physical/public-accommodation access, not internal compliance-program administration. None of the three, individually or together, supports cpa-001 through cpa-008's checklist duties, confirming the audit's finding; the round-one 'replace' only substituted one wrong statute number (§802.1/§805) for another wrong one (§801/§801.01) without ever addressing that the underlying authorities don't cover the claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III (28 CFR 36); CA Business and Professions Code §801 / §801.01 (malpractice settlement/arbitration-award/civil-judgment reporting); CA Labor Code §3700 (workers' compensation insurance mandate)",
              "url": "https://law.justia.com/codes/california/2022/code-bpc/division-2/chapter-1/article-11/section-801-01/"
            }
          },
          "source": "No single named authority establishes these program-management duties; they are standard compliance-program practice drawn from HIPAA Privacy/Security Rule administrative-safeguard expectations, Cal/OSHA IIPP (Title 8 CCR §3203) recordkeeping norms, and board-licensing best practice, none of which is textually cited here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "monthly",
      "id": "cpa-008",
      "kind": "compliance",
      "materials": [
        "regulatory change log",
        "state board newsletter",
        "federal register watch list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the state dental board newsletter, HHS OCR guidance updates, OSHA rule updates, and relevant federal register notices on a set schedule.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Monitor regulatory sources"
        },
        {
          "detail": "When a new law takes effect or a rule is finalized, capture its citation, effective date, and a one-line summary of what it changes.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Flag a new or finalized rule"
        },
        {
          "detail": "Check whether the change affects the policy manual, the compliance calendar, the training matrix, or day-to-day workflow, and note which.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Assess impact on current policy"
        },
        {
          "detail": "Summarize the change and its estimated impact for the practice owner, including any deadline for compliance.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Brief the practice owner"
        },
        {
          "detail": "Practice owner reviews the proposed response and approves before any policy manual language is changed.\n\nWhy: Policy changes bind staff conduct; the owner approves before the change takes effect.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner decision before policy is amended.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner decision before policy is amended",
          "why": "Policy changes bind staff conduct; the owner approves before the change takes effect."
        },
        {
          "detail": "Hand the approved change to the policy manual version control process (protocol cpa-003) for drafting and staff acknowledgment.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Route the change into the policy manual process"
        },
        {
          "detail": "Log the citation, effective date, impact assessment, and what action was taken in the regulatory change log.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the regulatory change and its disposition"
        },
        {
          "detail": "Change monitored and dispositioned",
          "id": "s8",
          "kind": "step",
          "title": "Change monitored and dispositioned"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Regulatory change monitoring and policy impact assessment — A new law takes effect, a board newsletter arrives, or a federal rule is finalized.",
      "title": "Regulatory change monitoring and policy impact assessment",
      "trigger": "A new law takes effect, a board newsletter arrives, or a federal rule is finalized",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023) — open reporting channel as a core compliance-program element",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023) — open reporting channel as a core compliance-program element",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "generic",
          "label": "Employer whistleblower and anti-retaliation protections exist under numerous federal and state laws (e.g., OSHA Section 11(c), the False Claims Act); the applicable statute depends on the subject matter of the report — consult counsel",
          "source": "Employer whistleblower and anti-retaliation protections exist under numerous federal and state laws (e.g., OSHA Section 11(c), the False Claims Act); the applicable statute depends on the subject matter of the report — consult counsel"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "cpa-009",
      "kind": "compliance",
      "materials": [
        "confidential reporting channel (hotline, email, or drop box)",
        "non-retaliation policy text",
        "confidential case log template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The employee raises a concern through any posted channel — direct to the compliance officer, a confidential email or drop box, or a phone line — including anonymously.\n\nWhy: Multiple channels exist because the direct supervisor may be the subject of the report.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Employee reports a suspected violation",
          "why": "Multiple channels exist because the direct supervisor may be the subject of the report."
        },
        {
          "detail": "Log date, channel used, whether the report is anonymous, a brief description of the concern, and any other staff named.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log intake details"
        },
        {
          "detail": "Does the report describe an immediate safety or patient-harm risk?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "escalate-now",
              "label": "Yes — escalate immediately"
            },
            {
              "goto": "s5",
              "id": "standard-track",
              "label": "No — route to the standard review timeline"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the report describe an immediate safety or patient-harm risk?"
        },
        {
          "detail": "Notify the practice owner and, where the facts require it, the state board or law enforcement without delay; do not wait for the standard review cycle.\n\nWhy: Some reports carry duties that run independently of the internal review process — early notice preserves the practice's own compliance posture.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Escalate to the owner and outside parties if required",
          "why": "Some reports carry duties that run independently of the internal review process — early notice preserves the practice's own compliance posture."
        },
        {
          "detail": "Assign a reviewer who is not the subject of the report and has no reporting relationship to the person named.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Assign an independent reviewer"
        },
        {
          "detail": "Before any scheduling change, discipline, or termination touching the reporting employee or any witness proceeds, the compliance officer or practice owner signs off in writing that the action is unrelated to the report.\n\nWhy: This is the control point that prevents retaliation from being disguised as an ordinary personnel decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Non-retaliation sign-off before any personnel action.",
            "role": "compliance officer by default; practice-owner signs instead when the compliance officer is the subject of the report",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Non-retaliation sign-off before any personnel action",
          "why": "This is the control point that prevents retaliation from being disguised as an ordinary personnel decision."
        },
        {
          "detail": "Interview the reporting employee, named individuals, and relevant witnesses; gather documents; keep interview notes separate from routine personnel files.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Investigate"
        },
        {
          "detail": "Send the reporting employee a written non-retaliation assurance and expected timeline, without confirming details that would identify witnesses.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Send written non-retaliation assurance"
        },
        {
          "detail": "If findings support corrective action against another employee, hand the case file to HR to run that action through the normal personnel process, kept administratively separate from the fact that a report was filed.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Hand off any corrective action to HR"
        },
        {
          "detail": "Monitor the reporting employee's schedule, assignments, and performance reviews for 30 days for any sign of retaliation.",
          "id": "s10",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 2592000,
          "title": "Monitor for retaliation signals"
        },
        {
          "detail": "Close the case in the confidential non-retaliation log with outcome, dates, and sign-offs; retain per the retention schedule.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the case record"
        },
        {
          "detail": "Non-retaliation case closed",
          "id": "s12",
          "kind": "step",
          "title": "Non-retaliation case closed"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Non-retaliation reporting channel and whistleblower protection — An employee reports a suspected violation or fears retaliation for reporting.",
      "title": "Non-retaliation reporting channel and whistleblower protection",
      "trigger": "An employee reports a suspected violation or fears retaliation for reporting",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA Labor Code §3700 — workers’ compensation insurance mandate",
          "source": "CA Labor Code §3700 — workers’ compensation insurance mandate",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=3700.&lawCode=LAB"
        },
        {
          "kind": "generic",
          "label": "Malpractice, general liability, property, cyber and disability coverage are standard practice risk-management lines; specific carrier terms and state minimums vary — confirm with the practice's broker — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Malpractice, general liability, property, cyber and disability coverage are standard practice risk-management lines; specific carrier terms and state minimums vary — confirm with the practice's broker"
          },
          "source": "Malpractice, general liability, property, cyber and disability coverage are standard practice risk-management lines; specific carrier terms and state minimums vary — confirm with the practice's broker — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "cpa-010",
      "kind": "compliance",
      "materials": [
        "insurance register",
        "prior policy declarations pages",
        "compliance calendar"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "A carrier sends a renewal notice, or the annual review date on the compliance calendar arrives, for malpractice, general liability, property, workers’ compensation, cyber, or disability coverage.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Renewal notice or annual review trigger arrives"
        },
        {
          "detail": "Pull the current policy limits, deductibles, named insureds, and expiration date from the insurance register for each line of coverage due.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current register entries"
        },
        {
          "detail": "Compare current limits against practice size, payroll, revenue, and any new exposure (new associate, new location, new equipment) since the last renewal.\n\nWhy: Coverage gaps most often open when the practice grows and nobody re-checks the old limits.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Review coverage against current exposure",
          "why": "Coverage gaps most often open when the practice grows and nobody re-checks the old limits."
        },
        {
          "detail": "Does coverage need to change at renewal?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "keep-as-is",
              "label": "Limits and terms remain adequate — renew as-is"
            },
            {
              "goto": "s10",
              "id": "adjust-coverage",
              "label": "Limits or terms need adjustment"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does coverage need to change at renewal?"
        },
        {
          "detail": "Confirm the renewal quote, premium, and effective date in writing before the current policy lapses.\n\nWhy: A lapse in malpractice coverage, even for a day, can leave open claims uninsured.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the renewal quote in writing",
          "why": "A lapse in malpractice coverage, even for a day, can leave open claims uninsured."
        },
        {
          "detail": "The practice owner reviews and approves the renewal terms and premium before the policy is bound.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner approval before binding.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner approval before binding"
        },
        {
          "detail": "Update the insurance register with the new policy number, limits, deductible, premium, effective and expiration dates, and file the declarations page.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the insurance register"
        },
        {
          "detail": "Update the annual compliance calendar with the next renewal date, tracked 90 days ahead.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the compliance calendar"
        },
        {
          "detail": "Renewal registered",
          "id": "s9",
          "kind": "step",
          "title": "Renewal registered"
        },
        {
          "detail": "Contact the insurance broker or carrier to request revised quotes reflecting the new limits, endorsements, or additional named insureds needed.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Consult the broker for revised quotes"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Malpractice, general liability, property, workers’ compensation, cyber and disability insurance renewal register — A policy renewal notice arrives, or coverage limits need review after growth.",
      "title": "Malpractice, general liability, property, workers’ compensation, cyber and disability insurance renewal register",
      "trigger": "A policy renewal notice arrives, or coverage limits need review after growth",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023) — auditing/monitoring and ongoing evaluation elements",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023) — auditing/monitoring and ongoing evaluation elements",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "generic",
          "label": "Periodic written reporting to practice ownership on the state of the compliance program is a standard small-practice governance practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Periodic written reporting to practice ownership on the state of the compliance program is a standard small-practice governance practice"
          },
          "source": "Periodic written reporting to practice ownership on the state of the compliance program is a standard small-practice governance practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "annual",
      "id": "cpa-011",
      "kind": "compliance",
      "materials": [
        "incident log",
        "training matrix",
        "mock audit findings",
        "retention/destruction log",
        "regulator correspondence log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "The annual reporting date arrives on the compliance calendar, or a practice sale or partnership buy-in is pending and current-state compliance documentation is requested.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Year-end or pre-transaction trigger arrives"
        },
        {
          "detail": "Pull the year's incident log entries, training completion rates, mock audit findings, retention/destruction log, and open regulator correspondence.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Gather the year's compliance data"
        },
        {
          "detail": "Draft the report: findings by category, open items with target dates, and a narrative summary of the year's compliance posture.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the report"
        },
        {
          "detail": "Attach cost estimates for each open remediation item (training, equipment, consulting, insurance) so the owner can prioritize by budget impact.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Attach budget estimates"
        },
        {
          "detail": "Are there any open items rated high-risk?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "flag-highrisk",
              "label": "Yes — flag for owner priority review"
            },
            {
              "goto": "s6",
              "id": "routine-review",
              "label": "No — route as a routine annual report"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Are there any open items rated high-risk?"
        },
        {
          "detail": "The practice owner reviews the report, discusses open items with the compliance officer, and sets remediation priorities and budget.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Owner reviews the report"
        },
        {
          "detail": "File the signed-off report and remediation plan with the compliance program records; retain per the retention schedule.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the signed-off report"
        },
        {
          "detail": "Distribute a summary, without confidential incident specifics, to relevant staff so next year's compliance priorities are visible.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Distribute a staff summary"
        },
        {
          "detail": "Annual report delivered",
          "id": "s9",
          "kind": "step",
          "title": "Annual report delivered"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Annual compliance report to the owner — findings, open items and budget — Year-end, or before a practice sale or partnership buy-in.",
      "title": "Annual compliance report to the owner — findings, open items and budget",
      "trigger": "Year-end, or before a practice sale or partnership buy-in",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA inspection and enforcement procedures 29 CFR 1903",
          "source": "OSHA inspection and enforcement procedures 29 CFR 1903"
        },
        {
          "kind": "regulation",
          "label": "HIPAA disclosures for judicial and administrative proceedings and law-enforcement purposes 45 CFR 164.512(e)-(f)",
          "source": "HIPAA disclosures for judicial and administrative proceedings and law-enforcement purposes 45 CFR 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.512"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "cpa-012",
      "kind": "compliance",
      "materials": [
        "regulator correspondence log",
        "compliance calendar",
        "prior correspondence file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "A letter, email, fax, or call arrives from OSHA, OCR, the dental board, DEA, EPA, or a state agency.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Correspondence from a regulator arrives"
        },
        {
          "detail": "Log the sender, date received, method, and a scan or copy of the correspondence in the regulator correspondence log.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the correspondence"
        },
        {
          "detail": "Identify any response deadline stated in the correspondence and calendar it with a reminder buffer of at least 5 business days before it is due.\n\nWhy: Missed regulator deadlines can convert a routine inquiry into an enforcement action.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify and calendar the deadline",
          "why": "Missed regulator deadlines can convert a routine inquiry into an enforcement action."
        },
        {
          "detail": "Does the correspondence require a substantive response, not just acknowledgment?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "substantive",
              "label": "Yes — prepare a substantive response"
            },
            {
              "goto": "s10",
              "id": "acknowledge-only",
              "label": "No — acknowledge receipt only"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the correspondence require a substantive response, not just acknowledgment?"
        },
        {
          "detail": "Draft the response using only verified facts and records; do not speculate or admit conclusions the practice has not confirmed.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the substantive response"
        },
        {
          "detail": "The practice owner and compliance officer review and approve the response, and loop in counsel if the correspondence alleges a violation or requests records, before anything is sent.\n\nWhy: A response sent to a regulator becomes part of the practice's official record; corrections after the fact are far harder than getting it right the first time.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sign-off before sending to a regulator.",
            "role": "practice-owner and compliance officer, with counsel where the matter is contested",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Sign-off before sending to a regulator",
          "why": "A response sent to a regulator becomes part of the practice's official record; corrections after the fact are far harder than getting it right the first time."
        },
        {
          "detail": "Send the approved response by the method and to the address the correspondence specifies, keeping proof of delivery.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Send the approved response"
        },
        {
          "detail": "File the correspondence, response, and delivery proof in the regulator correspondence log with the deadline marked closed.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Close the correspondence record"
        },
        {
          "detail": "Regulator correspondence closed",
          "id": "s9",
          "kind": "step",
          "title": "Regulator correspondence closed"
        },
        {
          "detail": "Send a brief written acknowledgment of receipt within the timeframe the agency requests, or within 5 business days if none is stated.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Send a receipt acknowledgment"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Regulator correspondence log and response deadline tracking — Any letter, email or call from OSHA, OCR, the dental board, DEA, EPA or a state agency.",
      "title": "Regulator correspondence log and response deadline tracking",
      "trigger": "Any letter, email or call from OSHA, OCR, the dental board, DEA, EPA or a state agency",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA disclosures for judicial and administrative proceedings and law-enforcement purposes 45 CFR 164.512(e)-(f)",
          "source": "HIPAA disclosures for judicial and administrative proceedings and law-enforcement purposes 45 CFR 164.512(e)-(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.512"
        },
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "cpa-013",
      "kind": "compliance",
      "materials": [
        "subpoena/records-request intake form",
        "legal correspondence log",
        "counsel contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer",
        "practice-owner",
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "A subpoena, court order, or attorney letter requesting patient records is delivered at the front desk or by mail.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "A process server or attorney delivers a request"
        },
        {
          "detail": "Do not release any record and do not discuss the request with the requester beyond confirming receipt; immediately notify the office manager or compliance officer.\n\nWhy: Front desk staff are not positioned to judge whether a request is validly served or properly authorized — that judgment belongs upstream.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Do not release; notify management",
          "why": "Front desk staff are not positioned to judge whether a request is validly served or properly authorized — that judgment belongs upstream."
        },
        {
          "detail": "Log the date received, method of service, requesting party, case number if any, and the specific records requested.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Log receipt of the request"
        },
        {
          "detail": "Is this a validly served subpoena/court order, or is a signed patient authorization attached?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "valid-process",
              "label": "Validly served subpoena/court order, or a signed patient authorization is attached"
            },
            {
              "goto": "s11",
              "id": "invalid-or-unclear",
              "label": "Not properly served, or no authorization and no order — do not comply yet"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is this a validly served subpoena/court order, or is a signed patient authorization attached?"
        },
        {
          "detail": "Limit the records pulled to exactly what the subpoena, order, or authorization specifies — no broader chart access than requested.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Limit the record set to what's requested"
        },
        {
          "detail": "The treating dentist reviews the record set for completeness and accuracy before it leaves the practice.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews the record set"
        },
        {
          "detail": "The compliance officer and practice owner confirm the legal basis, the scope, and the delivery method (certified mail, secure portal, or in-person to the court) before release.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sign-off before release.",
            "role": "dentist, compliance officer and practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Sign-off before release"
        },
        {
          "detail": "Release exactly the scoped record set through the confirmed method, with a delivery receipt or filing confirmation kept on file.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Release the scoped record set"
        },
        {
          "detail": "File the request, the legal-basis determination, counsel correspondence if any, and proof of release in the legal correspondence log.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the request and release record"
        },
        {
          "detail": "Records request closed",
          "id": "s10",
          "kind": "step",
          "title": "Records request closed"
        },
        {
          "detail": "Route the request to the practice's attorney before any response; do not release records or confirm or deny a patient relationship until counsel advises.\n\nWhy: HIPAA §164.512(e)-(f) permits disclosure for judicial and law-enforcement purposes only under specific conditions — releasing outside those conditions is a reportable breach.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Hold pending counsel review.",
            "role": "practice-owner/dentist, with counsel",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Hold pending counsel review",
          "why": "HIPAA §164.512(e)-(f) permits disclosure for judicial and law-enforcement purposes only under specific conditions — releasing outside those conditions is a reportable breach."
        },
        {
          "detail": "Follow counsel's written direction: comply, object, seek a protective order, or decline, and document which.",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Follow counsel's written direction"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Subpoena, court order or attorney records request — A process server delivers a subpoena, or an attorney requests records with or without a patient authorization.",
      "title": "Subpoena, court order or attorney records request",
      "trigger": "A process server delivers a subpoena, or an attorney requests records with or without a patient authorization",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA Business and Professions Code §802.1 / §805 — malpractice settlement/judgment and adverse-action reporting duties",
          "source": "CA Business and Professions Code §802.1 / §805 — malpractice settlement/judgment and adverse-action reporting duties"
        },
        {
          "kind": "generic",
          "label": "California's Medical Injury Compensation Reform Act (MICRA, Cal. Civ. Code §3333.2 et seq.) sets a statutory framework for malpractice damages; exact figures and procedure are counsel's determination, not this template's",
          "source": "California's Medical Injury Compensation Reform Act (MICRA, Cal. Civ. Code §3333.2 et seq.) sets a statutory framework for malpractice damages; exact figures and procedure are counsel's determination, not this template's",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=3333.2.&lawCode=CIV"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "cpa-014",
      "kind": "compliance",
      "materials": [
        "malpractice policy declarations",
        "litigation hold notice template",
        "compliance incident log",
        "legal file (kept separate from the clinical record)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "A patient's attorney sends a written demand or notice of intent to sue, or the practice/dentist is served with a malpractice suit.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "A demand letter or suit is received"
        },
        {
          "detail": "Preserve the complete original patient record exactly as it stands — do not add, alter, or amend any entry from this point forward.\n\nWhy: Any post-claim alteration of the record, even a well-intentioned correction, can be read as spoliation and can destroy the defense.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Preserve the record unaltered",
          "why": "Any post-claim alteration of the record, even a well-intentioned correction, can be read as spoliation and can destroy the defense."
        },
        {
          "detail": "The dentist and practice owner do not contact the patient, discuss the matter with staff beyond a need-to-know basis, or make any statement of fault, before speaking with malpractice defense counsel.\n\nWhy: Sympathetic statements made in good faith are routinely used as admissions; counsel should shape the first contact, if any.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Do not contact the patient or discuss the case before counsel.",
            "role": "dentist and practice-owner",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Do not contact the patient or discuss the case before counsel",
          "why": "Sympathetic statements made in good faith are routinely used as admissions; counsel should shape the first contact, if any."
        },
        {
          "detail": "Notify the malpractice carrier immediately per the policy's claims-reporting clause; most policies require prompt notice or coverage can be denied.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the malpractice carrier"
        },
        {
          "detail": "Does statute or the malpractice carrier require a formal report of this claim?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "report-required",
              "label": "Yes — file the required report within the statutory/policy window"
            },
            {
              "goto": "s7",
              "id": "no-report-yet",
              "label": "No formal reporting duty triggered at this stage"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does statute or the malpractice carrier require a formal report of this claim?"
        },
        {
          "detail": "File the required report (e.g., to the state dental board or carrier) within the deadline, coordinating language with defense counsel.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the required report"
        },
        {
          "detail": "Confirm defense counsel assignment from the carrier, or retain independent counsel, and route all further communication with the claimant through counsel.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm defense counsel"
        },
        {
          "detail": "Enter the claim in the compliance incident log with dates, carrier claim number, and counsel contact — the case narrative stays in the legal file, not the routine incident log.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the claim"
        },
        {
          "detail": "Issue a litigation hold notice to all staff who may hold relevant records, emails, or texts, instructing them to preserve and not delete anything related to the matter.\n\nWhy: Routine document-retention/destruction schedules must pause the moment litigation is reasonably anticipated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Litigation hold issued.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Litigation hold issued",
          "why": "Routine document-retention/destruction schedules must pause the moment litigation is reasonably anticipated."
        },
        {
          "detail": "Brief only the staff who need to know that they may not discuss the matter outside the practice and should refer any inquiry to the practice owner or counsel.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Brief staff on a need-to-know basis"
        },
        {
          "detail": "Maintain the legal file separately from the clinical record, with counsel correspondence, carrier correspondence, and the litigation hold acknowledgment.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Maintain the separate legal file"
        },
        {
          "detail": "Claim routed to counsel and carrier",
          "id": "s12",
          "kind": "step",
          "title": "Claim routed to counsel and carrier"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Malpractice claim, notice of intent or attorney demand letter — A patient's attorney sends a demand, or a suit is served naming the dentist or practice.",
      "title": "Malpractice claim, notice of intent or attorney demand letter",
      "trigger": "A patient's attorney sends a demand, or a suit is served naming the dentist or practice",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA bloodborne pathogens recordkeeping 29 CFR 1910.1030(h) and injury/illness recordkeeping retention 29 CFR 1904",
          "source": "OSHA bloodborne pathogens recordkeeping 29 CFR 1910.1030(h) and injury/illness recordkeeping retention 29 CFR 1904",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol6/xml/CFR-2024-title29-vol6-sec1910-1030.xml"
        },
        {
          "kind": "statute",
          "label": "Americans with Disabilities Act Title III public accommodations, 28 CFR Part 36",
          "source": "Americans with Disabilities Act Title III public accommodations, 28 CFR Part 36",
          "url": "https://www.ada.gov/resources/title-iii-primer/"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "cpa-015",
      "kind": "compliance",
      "materials": [
        "visitor log",
        "fire safety plan and inspection records",
        "biohazard/waste disposal log",
        "occupancy certificate"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "A local health department, fire marshal, or building inspector arrives, with or without advance notice, to check waste handling, water lines, fire safety, or occupancy.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "An inspector arrives"
        },
        {
          "detail": "Ask for photo identification and a business card, and note the agency, inspector name, and stated purpose.\n\nWhy: Confirms this is the agency it claims to be before any access is granted.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify identification",
          "why": "Confirms this is the agency it claims to be before any access is granted."
        },
        {
          "detail": "Notify the office manager or compliance officer immediately and have them meet the inspector before any walkthrough begins.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the office manager"
        },
        {
          "detail": "Is this a routine/scheduled inspection or an unannounced complaint-driven visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "routine",
              "label": "Routine/scheduled — proceed with standard escort"
            },
            {
              "goto": "s11",
              "id": "complaint-driven",
              "label": "Unannounced, complaint-driven — confirm scope before proceeding"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a routine/scheduled inspection or an unannounced complaint-driven visit?"
        },
        {
          "detail": "Escort the inspector at all times; do not leave them unattended in clinical or records areas.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Escort the inspector at all times"
        },
        {
          "detail": "Note every item the inspector flags, cites, or asks to be corrected, with the specific code section if given.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log inspection findings"
        },
        {
          "detail": "Did the inspector issue a citation or notice of violation?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "citation-issued",
              "label": "Yes — a citation/notice was issued"
            },
            {
              "goto": "s9",
              "id": "no-citation",
              "label": "No — informal notes only"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did the inspector issue a citation or notice of violation?"
        },
        {
          "detail": "Open a corrective action plan entry in the compliance incident log with the deficiency, responsible person, and correction deadline.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Open a corrective action plan"
        },
        {
          "detail": "File the visit summary, inspector contact information, findings, and any citation in the compliance file.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the visit summary"
        },
        {
          "detail": "Inspection visit closed",
          "id": "s10",
          "kind": "step",
          "title": "Inspection visit closed"
        },
        {
          "detail": "Ask the inspector to state the specific complaint or trigger and the areas it covers before opening areas outside that scope.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Clarify the scope"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Local health department, fire marshal or building inspector visit — A city or county inspector arrives to check waste, water, fire safety or occupancy.",
      "title": "Local health department, fire marshal or building inspector visit",
      "trigger": "A city or county inspector arrives to check waste, water, fire safety or occupancy",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA disclosures for law-enforcement purposes 45 CFR 164.512(f)",
          "source": "HIPAA disclosures for law-enforcement purposes 45 CFR 164.512(f)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.512"
        },
        {
          "kind": "generic",
          "label": "A warrant signed by a judge is generally what authorizes law-enforcement entry into non-public areas of a business; an administrative or agency-issued warrant does not carry the same authority — the specific rule is fact-dependent and this is not a substitute for counsel's real-time advice",
          "source": "A warrant signed by a judge is generally what authorizes law-enforcement entry into non-public areas of a business; an administrative or agency-issued warrant does not carry the same authority — the specific rule is fact-dependent and this is not a substitute for counsel's real-time advice"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "cpa-016",
      "kind": "compliance",
      "materials": [
        "warrant-verification checklist",
        "legal correspondence log",
        "counsel contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Law-enforcement or immigration-enforcement officers arrive asking for a patient, an employee, records, or access to non-public areas.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Officers arrive at the front desk"
        },
        {
          "detail": "Ask for badge/photo ID and the name of the agency; write down the officer's name, badge number, and agency.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify officer identification"
        },
        {
          "detail": "Immediately notify the office manager or practice owner; do not answer substantive questions or grant access while waiting.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the office manager"
        },
        {
          "detail": "Do the officers have a signed judicial warrant covering the specific area or records requested?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "judicial-warrant",
              "label": "Yes — a signed judicial warrant covers the area/records requested"
            },
            {
              "goto": "s10",
              "id": "no-judicial-warrant",
              "label": "No judicial warrant, or it doesn't cover what's requested"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Do the officers have a signed judicial warrant covering the specific area or records requested?"
        },
        {
          "detail": "Confirm the warrant is signed by a judge, current, and specific to the area or records requested before allowing entry or releasing anything; photograph or copy the warrant for the file.\n\nWhy: A warrant that is expired, unsigned, or broader than what's shown must not be treated as authorizing access.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Warrant verified before access is granted.",
            "role": "office manager and, where reachable, practice-owner or counsel",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "Warrant verified before access is granted",
          "why": "A warrant that is expired, unsigned, or broader than what's shown must not be treated as authorizing access."
        },
        {
          "detail": "Grant access or release records strictly limited to what the warrant specifies; escort officers at all times.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Grant only scoped access"
        },
        {
          "detail": "File a written account of the visit — officers' names, agency, badge numbers, what was asked, what was and was not provided, and counsel's guidance — in the legal correspondence log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the visit"
        },
        {
          "detail": "Brief staff on what occurred, on a need-to-know basis, and remind them to refer any follow-up inquiry to the office manager or counsel rather than answering directly.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Debrief staff on a need-to-know basis"
        },
        {
          "detail": "Law-enforcement/immigration visit closed",
          "id": "s9",
          "kind": "step",
          "title": "Law-enforcement/immigration visit closed"
        },
        {
          "detail": "Without a judicial warrant, keep officers in the public waiting area; non-public areas (clinical, records, staff-only) are not opened, and no patient or employee information is confirmed or denied.\n\nWhy: A warrant issued by a judge is what authorizes entry to non-public space; other forms of request do not carry that authority.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Restrict to the public waiting area",
          "why": "A warrant issued by a judge is what authorizes entry to non-public space; other forms of request do not carry that authority."
        },
        {
          "detail": "Call the practice's attorney for guidance before proceeding further, and inform the officers that counsel is being contacted.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Call counsel for guidance"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Law-enforcement or immigration-enforcement officers at the front desk — Officers ask for a patient, an employee, records, or access to non-public areas, with or without a warrant.",
      "title": "Law-enforcement or immigration-enforcement officers at the front desk",
      "trigger": "Officers ask for a patient, an employee, records, or access to non-public areas, with or without a warrant",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule permitted uses/disclosures 45 CFR 164.502 and 164.510 (no disclosure of PHI to media without patient authorization, including confirming a named individual is a patient)",
          "source": "HIPAA Privacy Rule permitted uses/disclosures 45 CFR 164.502 and 164.510 (no disclosure of PHI to media without patient authorization, including confirming a named individual is a patient)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.502"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "cpa-017",
      "kind": "compliance",
      "materials": [
        "media inquiry log",
        "standard holding statement template",
        "HIPAA no-comment script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "marketing",
        "compliance-officer",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Whoever takes the call or the walk-in gets the reporter's name, outlet, phone/email, deadline, and the specific topic they are asking about, in writing.\n\nWhy: A specific deadline and topic tell the owner how urgent the response is and whether legal counsel needs to be looped in before anyone speaks.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive the media inquiry",
          "why": "A specific deadline and topic tell the owner how urgent the response is and whether legal counsel needs to be looped in before anyone speaks."
        },
        {
          "detail": "The staff member who took the call states only that the inquiry has been logged and will be routed to the practice owner; they give no information about the practice, any patient, or any incident, even off the record.\n\nWhy: HIPAA bars confirming that a named person is a patient without authorization (45 CFR 164.502), and an off-hand staff comment cannot be un-said once printed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: No one but the designated spokesperson comments, ever.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "front-desk",
          "title": "No one but the designated spokesperson comments, ever",
          "why": "HIPAA bars confirming that a named person is a patient without authorization (45 CFR 164.502), and an off-hand staff comment cannot be un-said once printed."
        },
        {
          "detail": "Enter the reporter's contact details, outlet, topic, and deadline in the media inquiry log with a timestamp.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the inquiry"
        },
        {
          "detail": "Front desk hands the logged inquiry to the practice owner (or the marketing lead if the owner has designated one) before the reporter's deadline.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Route the inquiry to the practice owner"
        },
        {
          "detail": "Assess what the inquiry is about",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "general-practice",
              "label": "General practice news, community event, or a positive feature"
            },
            {
              "goto": "s11",
              "id": "incident-or-patient",
              "label": "A specific patient, a complaint, litigation, or an adverse incident"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Assess what the inquiry is about"
        },
        {
          "detail": "Write a brief, factual statement (or a holding statement buying time) using the standard template; never include patient names, PHI, or speculation about an ongoing matter.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Draft the response or holding statement"
        },
        {
          "detail": "Compliance officer reviews the drafted statement for any PHI or unauthorized patient reference before it is sent to the reporter.\n\nWhy: A second reader catches a slipped identifying detail the drafter is too close to the situation to see.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance check before the statement goes out.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance check before the statement goes out",
          "why": "A second reader catches a slipped identifying detail the drafter is too close to the situation to see."
        },
        {
          "detail": "Owner or marketing lead sends the approved statement directly to the reporter, in writing where possible.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Send the response to the reporter"
        },
        {
          "detail": "File the sent statement and, once published, a copy or link to the resulting coverage in the media inquiry log.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the final response and any resulting coverage"
        },
        {
          "detail": "Media inquiry closed",
          "id": "s10",
          "kind": "step",
          "title": "Media inquiry closed"
        },
        {
          "detail": "For any inquiry touching a named patient, a complaint, litigation, or an adverse incident, the owner reaches the practice's attorney before any statement is made.\n\nWhy: A premature statement about an incident under investigation can prejudice a later legal defense, and any patient detail released without authorization is a separate HIPAA violation.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Consult legal counsel before responding",
          "why": "A premature statement about an incident under investigation can prejudice a later legal defense, and any patient detail released without authorization is a separate HIPAA violation."
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Media or journalist inquiry about the practice, a patient or an incident — A reporter calls, emails or shows up asking for comment.",
      "title": "Media or journalist inquiry about the practice, a patient or an incident",
      "trigger": "A reporter calls, emails or shows up asking for comment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "statute",
          "label": "CA B&P §802.1 / §805 (dental board reporting); a dentist practicing on a lapsed license risks unlicensed-practice exposure and DEA registration lapse bars controlled-substance prescribing (21 CFR 1301.13)",
          "source": "CA B&P §802.1 / §805 (dental board reporting); a dentist practicing on a lapsed license risks unlicensed-practice exposure and DEA registration lapse bars controlled-substance prescribing (21 CFR 1301.13)"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "cpa-018",
      "kind": "compliance",
      "materials": [
        "state board license lookup",
        "DEA registration status lookup",
        "compliance calendar",
        "schedule board"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Whoever finds the expired renewal deadline or a license/DEA lookup returning expired, probation, or restricted status confirms it a second time directly on the state board or DEA verification site.\n\nWhy: A license lookup site can lag or glitch; confirming on the authoritative source before acting prevents a false-positive schedule freeze.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Discover and confirm the lapse",
          "why": "A license lookup site can lag or glitch; confirming on the authoritative source before acting prevents a false-positive schedule freeze."
        },
        {
          "detail": "Practice owner immediately stops the dentist from performing any procedure (or, for a DEA lapse, from prescribing any controlled substance) covered by the lapsed credential, effective immediately, before another patient is seen.\n\nWhy: Treating a patient on an expired license or prescribing on a lapsed DEA registration exposes the dentist to unlicensed-practice or unauthorized-prescribing liability with no cure after the fact.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Freeze clinical activity under the lapsed credential.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Freeze clinical activity under the lapsed credential",
          "why": "Treating a patient on an expired license or prescribing on a lapsed DEA registration exposes the dentist to unlicensed-practice or unauthorized-prescribing liability with no cure after the fact."
        },
        {
          "detail": "Compliance officer pulls the chart and prescription records for the full window between the credential's actual expiration/restriction date and the date the lapse was discovered, to find any procedure performed or prescription written before the lapse was caught.\n\nWhy: The trigger for this protocol is a deadline passing unnoticed, so discovery routinely lags the actual lapse date; the forward-looking freeze and reschedule below do not address care already rendered on a lapsed credential.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Retrospectively review treatment already completed during the lapse window",
          "why": "The trigger for this protocol is a deadline passing unnoticed, so discovery routinely lags the actual lapse date; the forward-looking freeze and reschedule below do not address care already rendered on a lapsed credential."
        },
        {
          "detail": "Was any procedure performed or prescription written on the lapsed credential before discovery?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "none-found",
              "label": "No treatment or prescriptions found in the lapse window"
            },
            {
              "goto": "s13",
              "id": "found",
              "label": "Treatment or prescriptions were completed on the lapsed credential"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Was any procedure performed or prescription written on the lapsed credential before discovery?"
        },
        {
          "detail": "Office manager pulls the schedule for the affected credential (all dentist appointments, or all controlled-substance prescriptions) from the moment of the lapse forward.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify affected patients and appointments"
        },
        {
          "detail": "Decide how to cover the frozen schedule",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "reschedule-all",
              "label": "Reschedule affected patients until the credential is restored"
            },
            {
              "goto": "s14",
              "id": "covering-dentist",
              "label": "Bring in a covering dentist with a current, verified credential"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide how to cover the frozen schedule"
        },
        {
          "detail": "Front desk contacts each affected patient to reschedule, using wording confirmed with counsel/compliance officer rather than a default no-disclosure script — the disclosure decision is made case-by-case, not assumed.\n\nWhy: Patients need continuity of care, but whether and how to reference the credential issue is a case-specific legal call, not a default front-desk script.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify and reschedule affected patients",
          "why": "Patients need continuity of care, but whether and how to reference the credential issue is a case-specific legal call, not a default front-desk script."
        },
        {
          "detail": "Dentist and office manager complete and submit the renewal, late-renewal, or reinstatement application to the state board or DEA the same day the lapse is confirmed.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "File the renewal or reinstatement application immediately"
        },
        {
          "detail": "Check whether the lapse itself must be self-reported",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "no-report-required",
              "label": "Administrative lapse with no independent reporting obligation"
            },
            {
              "goto": "s15",
              "id": "report-required",
              "label": "State board rules require self-reporting the lapse or any restriction"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Check whether the lapse itself must be self-reported"
        },
        {
          "detail": "Practice owner confirms the state board or DEA lookup now shows active, unrestricted status before the dentist resumes any frozen procedure or prescribing.\n\nWhy: A pending application is not a restored credential; the freeze from the first gate does not lift until confirmation is independently verified.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm restoration before resuming clinical activity.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Confirm restoration before resuming clinical activity",
          "why": "A pending application is not a restored credential; the freeze from the first gate does not lift until confirmation is independently verified."
        },
        {
          "detail": "Enter the lapse, freeze date, restoration date, and root cause in the compliance incident log, and add or correct the 90-day lead-time reminder in the compliance calendar so it does not recur.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident and fix the calendar gap"
        },
        {
          "detail": "Credential restored and schedule unfrozen",
          "id": "s12",
          "kind": "step",
          "title": "Credential restored and schedule unfrozen"
        },
        {
          "detail": "Compliance officer sends the list of already-completed treatment or prescriptions performed on the lapsed credential to defense counsel and the malpractice carrier for a determination on required patient disclosure and any board or carrier reporting duty, kept separate from the forward-looking reschedule path.\n\nWhy: Disclosure and reporting obligations for care already rendered are a distinct legal determination from simply rescheduling future appointments.",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Route the retrospective finding to counsel and the malpractice carrier",
          "why": "Disclosure and reporting obligations for care already rendered are a distinct legal determination from simply rescheduling future appointments."
        },
        {
          "detail": "Confirm the covering dentist's own license and DEA registration are current and unrestricted via the state board and DEA lookup before they take over any appointment.\n\nWhy: Substituting one unverified credential for another does not fix the exposure.",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify the covering dentist's credentials before they see any patient",
          "why": "Substituting one unverified credential for another does not fix the exposure."
        },
        {
          "detail": "Compliance officer prepares and the dentist signs any self-report the state board requires for the lapse or restriction, within the board's stated timeframe.",
          "id": "s15",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the required board report"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Dentist license, DEA registration, permit or CE lapse discovered — A renewal deadline passes unnoticed, or a license check returns expired, probation or restricted status.",
      "title": "Dentist license, DEA registration, permit or CE lapse discovered",
      "trigger": "A renewal deadline passes unnoticed, or a license check returns expired, probation or restricted status",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "statute",
          "label": "CA Labor Code §3700 (workers' compensation insurance mandate for any employer); most state dental boards require continuous malpractice coverage or disclosure of self-insured status to patients",
          "source": "CA Labor Code §3700 (workers' compensation insurance mandate for any employer); most state dental boards require continuous malpractice coverage or disclosure of self-insured status to patients"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "cpa-019",
      "kind": "compliance",
      "materials": [
        "insurance policy renewal register",
        "broker contact",
        "cancellation/non-renewal notice"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Office manager confirms the effective date of cancellation or non-renewal, which policy is affected (malpractice, general liability, or workers' comp), and the stated reason.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and read the cancellation or non-renewal notice"
        },
        {
          "detail": "Office manager escalates the notice to the practice owner the same day it is received, not at the next scheduled check-in.\n\nWhy: A coverage gap is a same-day exposure, not a routine agenda item.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the practice owner immediately",
          "why": "A coverage gap is a same-day exposure, not a routine agenda item."
        },
        {
          "detail": "Determine whether a coverage gap has already occurred",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "before-effective-date",
              "label": "Notice received before the cancellation effective date — still covered today"
            },
            {
              "goto": "s11",
              "id": "already-lapsed",
              "label": "Effective date has already passed or payment was missed and grace period expired"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Determine whether a coverage gap has already occurred"
        },
        {
          "detail": "Practice owner or office manager calls the broker to determine the cause (missed payment, underwriting non-renewal, carrier exit) and the fastest path to reinstatement or replacement coverage.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Call the insurance broker or carrier immediately"
        },
        {
          "detail": "Choose the resolution path",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "reinstate",
              "label": "Pay the missed premium and reinstate the existing policy"
            },
            {
              "goto": "s6",
              "id": "new-carrier",
              "label": "Bind a new policy with a different carrier"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Choose the resolution path"
        },
        {
          "detail": "Obtain a certificate of insurance or binder from the broker or carrier showing the effective date and coverage limits before resuming any clinical activity that was halted.\n\nWhy: A verbal assurance from a broker is not proof of coverage; only a written certificate or binder is.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Get written confirmation of coverage in force",
          "why": "A verbal assurance from a broker is not proof of coverage; only a written certificate or binder is."
        },
        {
          "detail": "Practice owner reviews the written certificate or binder and confirms coverage is active before lifting any halt on clinical activity.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner confirms coverage before clinical activity resumes.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner confirms coverage before clinical activity resumes"
        },
        {
          "detail": "Enter the new or reinstated policy's carrier, effective date, expiration, and limits into the insurance policy renewal register; correct the compliance calendar's lead-time reminder for this policy.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the insurance policy register and compliance calendar"
        },
        {
          "detail": "Record the lapse, its cause, any gap duration, and the corrective action (e.g. an automated payment or an earlier renewal trigger) in the compliance incident log.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the lapse as a compliance incident"
        },
        {
          "detail": "Coverage restored and documented",
          "id": "s10",
          "kind": "step",
          "title": "Coverage restored and documented"
        },
        {
          "detail": "Practice owner decides whether the practice can continue seeing patients without malpractice coverage in force; for a confirmed malpractice lapse, clinical activity stops until interim or bridge coverage is confirmed in writing by the broker or carrier.\n\nWhy: Treating patients with no malpractice coverage in force exposes the owner and every treating dentist personally, and cannot be fixed retroactively.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Halt clinical activity dependent on lapsed coverage.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Halt clinical activity dependent on lapsed coverage",
          "why": "Treating patients with no malpractice coverage in force exposes the owner and every treating dentist personally, and cannot be fixed retroactively."
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Malpractice, general liability or workers’ compensation insurance lapse — A cancellation or non-renewal notice arrives, or a premium payment was missed.",
      "title": "Malpractice, general liability or workers’ compensation insurance lapse",
      "trigger": "A cancellation or non-renewal notice arrives, or a premium payment was missed",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA documentation retention 45 CFR 164.316 sets a floor; a litigation hold suspends the normal retention/destruction schedule for any record reasonably related to the matter, a general functional-equivalent duty once a claim is reasonably anticipated (not itself a dental-specific citation)",
          "source": "HIPAA documentation retention 45 CFR 164.316 sets a floor; a litigation hold suspends the normal retention/destruction schedule for any record reasonably related to the matter, a general functional-equivalent duty once a claim is reasonably anticipated (not itself a dental-specific citation)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "cpa-020",
      "kind": "compliance",
      "materials": [
        "litigation hold notice template",
        "record inventory",
        "IT backup/retention system access"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "it-vendor",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Whoever receives the claim letter, complaint, subpoena, or investigation notice hands it unopened-in-substance to the compliance officer and practice owner the same day, with the date and method of receipt logged.\n\nWhy: The clock on the duty to preserve starts when a claim is reasonably anticipated, not when the practice decides to act on it.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and log the triggering notice",
          "why": "The clock on the duty to preserve starts when a claim is reasonably anticipated, not when the practice decides to act on it."
        },
        {
          "detail": "Compliance officer and practice owner review the notice with the practice's attorney to determine which patient(s), date range, and record types are reasonably related to the matter.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Consult legal counsel on scope"
        },
        {
          "detail": "List every record category reasonably related to the matter: the patient chart, radiographs, photographs, billing and insurance records, appointment history, staff communications referencing the patient or incident, and relevant equipment/sterilization logs for the date in question.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Define the hold scope"
        },
        {
          "detail": "Compliance officer issues a written hold notice naming the scope, effective immediately, to every staff member and system (paper files, PMS, email, backups) that could otherwise destroy or overwrite an in-scope record.\n\nWhy: Destroying or auto-purging a relevant record after a hold should have been in place can itself become an independent legal problem, separate from the underlying claim.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Issue the litigation hold before anything is destroyed.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Issue the litigation hold before anything is destroyed",
          "why": "Destroying or auto-purging a relevant record after a hold should have been in place can itself become an independent legal problem, separate from the underlying claim."
        },
        {
          "detail": "IT vendor pauses any automated backup rotation, email auto-deletion, or scheduled destruction-log purge that could reach records in the defined scope.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Suspend automated retention and destruction for the in-scope records"
        },
        {
          "detail": "Every staff member with access to in-scope records confirms in writing they received the hold notice and understand what they must not alter or delete.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect staff acknowledgment of the hold"
        },
        {
          "detail": "Compliance officer makes and securely stores a dated copy of every in-scope record as it existed at the time the hold was issued, separate from the working file.\n\nWhy: A preserved snapshot proves the record's state at the time of the hold if the working copy is later questioned.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Preserve a dated, unaltered copy of the in-scope records",
          "why": "A preserved snapshot proves the record's state at the time of the hold if the working copy is later questioned."
        },
        {
          "detail": "Compliance officer confirms to the practice owner that the hold is fully in effect: scope defined, notice issued, auto-destruction suspended, and staff acknowledged.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Brief the practice owner on hold status"
        },
        {
          "detail": "Compliance officer checks in with counsel weekly on the matter's status and keeps the hold in force until counsel confirms in writing it can be released.",
          "id": "s9",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 604800,
          "title": "Monitor the hold until counsel releases it"
        },
        {
          "detail": "Release the hold or keep it in place",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "keep-hold",
              "label": "Matter is still open — keep the hold in force"
            },
            {
              "goto": "s11",
              "id": "release-hold",
              "label": "Counsel confirms in writing the matter is resolved or closed"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Release the hold or keep it in place"
        },
        {
          "detail": "Log the notice date, scope, issuance date, staff acknowledgments, and release date (with counsel's written release) in the compliance incident log; resume normal retention/destruction scheduling for the released records.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the hold's full lifecycle"
        },
        {
          "detail": "Litigation hold released and logged",
          "id": "s12",
          "kind": "step",
          "title": "Litigation hold released and logged"
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Litigation hold and record preservation — Any credible notice of a claim, complaint, subpoena or investigation is received.",
      "title": "Litigation hold and record preservation",
      "trigger": "Any credible notice of a claim, complaint, subpoena or investigation is received",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA disclosures for judicial and administrative proceedings 45 CFR 164.512(e) governs what PHI may be produced in response to a subpoena, court order, or discovery request",
          "source": "HIPAA disclosures for judicial and administrative proceedings 45 CFR 164.512(e) governs what PHI may be produced in response to a subpoena, court order, or discovery request",
          "url": "https://www.ecfr.gov/current/title-45/section-164.512"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "cpa-021",
      "kind": "compliance",
      "materials": [
        "subpoena or deposition notice",
        "malpractice carrier contact",
        "record retrieval / litigation-hold checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Dentist or practice owner reads the document to determine whether it is a subpoena for testimony, a deposition notice, or an informal attorney request to serve as an expert witness, and notes the deadline and the requesting party.\n\nWhy: A subpoena for testimony (this protocol) is a different legal event from a subpoena for records only, which follows the practice's records-request procedure instead.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm what was served and by whom",
          "why": "A subpoena for testimony (this protocol) is a different legal event from a subpoena for records only, which follows the practice's records-request procedure instead."
        },
        {
          "detail": "Is this related to the dentist's own patient care?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "own-care",
              "label": "The matter involves the dentist's own treatment of a patient"
            },
            {
              "goto": "s10",
              "id": "third-party-expert",
              "label": "The dentist is being asked to opine on another dentist's care as a retained expert"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this related to the dentist's own patient care?"
        },
        {
          "detail": "Practice owner or dentist notifies the malpractice insurance carrier of the subpoena or deposition notice as soon as it is served, per the policy's notice requirements.\n\nWhy: Most malpractice policies require prompt notice of any legal proceeding touching the insured's care, and a carrier can often provide or fund counsel for the deposition.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the malpractice carrier",
          "why": "Most malpractice policies require prompt notice of any legal proceeding touching the insured's care, and a carrier can often provide or fund counsel for the deposition."
        },
        {
          "detail": "Dentist meets with the carrier-assigned or retaining attorney to review the scope of the subpoena, what records may be discussed under 45 CFR 164.512(e), and how to handle questions outside that scope, before the deposition or testimony date.\n\nWhy: Testifying without counsel preparation risks disclosing PHI beyond what the subpoena permits, or making a statement that damages a related legal position.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Meet with counsel before any testimony or opinion is given.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Meet with counsel before any testimony or opinion is given",
          "why": "Testifying without counsel preparation risks disclosing PHI beyond what the subpoena permits, or making a statement that damages a related legal position."
        },
        {
          "detail": "Compliance officer confirms whether the patient record(s) relevant to the testimony are already under an active litigation hold (protocol cpa-020) and, if not, opens one.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check whether related records are already under litigation hold"
        },
        {
          "detail": "Dentist attends with counsel present, answering only within the scope counsel reviewed and declining to speculate beyond personal knowledge or the engaged expert scope.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Attend the deposition or give testimony"
        },
        {
          "detail": "Immediately after, dentist and counsel review what was covered and whether any follow-up production or correction is needed.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Debrief with counsel and the practice owner"
        },
        {
          "detail": "Compliance officer records the matter, the date served, the carrier or engagement notified, the proceeding date, and its outcome in the compliance incident log.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the legal event"
        },
        {
          "detail": "Testimony or expert engagement completed and logged",
          "id": "s9",
          "kind": "step",
          "title": "Testimony or expert engagement completed and logged"
        },
        {
          "detail": "Compliance officer confirms the retaining attorney provides a written engagement letter and scope before the dentist reviews any records or forms an opinion.\n\nWhy: An informal opinion given before a scope is defined can create obligations the dentist did not intend and is harder to walk back once given.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Route the expert-witness request through a formal engagement",
          "why": "An informal opinion given before a scope is defined can create obligations the dentist did not intend and is harder to walk back once given."
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Dentist subpoenaed to testify, deposed or asked to serve as expert witness — A subpoena for testimony (not records) or a deposition notice is served, or an attorney asks the dentist to opine on another dentist's care.",
      "title": "Dentist subpoenaed to testify, deposed or asked to serve as expert witness",
      "trigger": "A subpoena for testimony (not records) or a deposition notice is served, or an attorney asks the dentist to opine on another dentist's care",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "source": "HHS OIG Compliance Program Guidance for Individual and Small Group Physician Practices (2000) and General Compliance Program Guidance (2023)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        },
        {
          "kind": "generic",
          "label": "Generic insurance-claim filing practice (loss documentation, timely notice, itemized proof of loss); not a dental-specific statute — a functional equivalent used across small-business property/cyber claims — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic insurance-claim filing practice (loss documentation, timely notice, itemized proof of loss); not a dental-specific statute — a functional equivalent used across small-business property/cyber claims"
          },
          "source": "Generic insurance-claim filing practice (loss documentation, timely notice, itemized proof of loss); not a dental-specific statute — a functional equivalent used across small-business property/cyber claims — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "HIPAA Breach Notification Rule 45 CFR §164.400-414: a four-factor risk assessment (§164.402 definition / §164.404(b)) determines whether an impermissible use or disclosure is a reportable breach, and notification is due without unreasonable delay and no later than 60 days after discovery",
          "source": "HIPAA Breach Notification Rule 45 CFR §164.400-414: a four-factor risk assessment (§164.402 definition / §164.404(b)) determines whether an impermissible use or disclosure is a reportable breach, and notification is due without unreasonable delay and no later than 60 days after discovery",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-D"
        }
      ],
      "class": "compliance-program-administration",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "cpa-022",
      "kind": "compliance",
      "materials": [
        "insurance policy renewal register",
        "damage/loss documentation (photos, receipts, equipment inventory)",
        "claim filing portal or broker contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Practice owner confirms what happened (flood, fire, theft, ransomware, or closure event), when, and takes immediate steps to prevent further loss (e.g. shutting off water, isolating an infected system).",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Identify and stabilize the loss"
        },
        {
          "detail": "Is this a cyber or data-related incident?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "not-cyber",
              "label": "Physical loss only (flood, fire, theft)"
            },
            {
              "goto": "s12",
              "id": "cyber-incident",
              "label": "Ransomware, breach, or other cyber incident"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is this a cyber or data-related incident?"
        },
        {
          "detail": "Photograph damage, list affected equipment and its approximate value, collect purchase receipts or depreciation records where available, and note the closure period if the practice could not operate.\n\nWhy: The claim payout depends on how well the loss is documented at the time, not on memory weeks later.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the loss",
          "why": "The claim payout depends on how well the loss is documented at the time, not on memory weeks later."
        },
        {
          "detail": "Pull the relevant policy (property, business-interruption, or cyber) from the insurance policy renewal register and confirm the coverage type, deductible, and the deadline for giving notice of the claim.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the policy for coverage and notice deadlines"
        },
        {
          "detail": "Practice owner or office manager submits initial notice of claim to the carrier or broker before the policy's notice deadline, even if full documentation is not yet complete.\n\nWhy: Missing a notice deadline can void an otherwise valid claim regardless of how strong the documentation later is.",
          "gate": {
            "ack": "I confirm I have completed this step as written: File notice of the claim within the policy deadline.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "File notice of the claim within the policy deadline",
          "why": "Missing a notice deadline can void an otherwise valid claim regardless of how strong the documentation later is."
        },
        {
          "detail": "Compile the documented damage, values, and business-interruption calculation (lost revenue during closure, if covered) into the carrier's proof-of-loss format.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare the itemized proof of loss"
        },
        {
          "detail": "Practice owner reviews the itemized proof of loss for accuracy and signs it before submission.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Owner reviews and signs the proof of loss"
        },
        {
          "detail": "Office manager submits the signed proof of loss and supporting documentation to the carrier through the claim portal or broker.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the completed claim"
        },
        {
          "detail": "Office manager checks in with the adjuster weekly and promptly supplies any additional documentation requested during the review.",
          "id": "s9",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 604800,
          "title": "Track adjuster review and respond to requests"
        },
        {
          "detail": "Log the claim number, filed date, documented loss amount, and final settlement amount in the insurance policy renewal register and the compliance incident log.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the claim outcome"
        },
        {
          "detail": "Claim filed and resolved",
          "id": "s11",
          "kind": "step",
          "title": "Claim filed and resolved"
        },
        {
          "detail": "Compliance officer confirms whether the incident also triggers a HIPAA breach risk assessment: the four-factor test at 45 CFR §164.402/164.404(b) determines whether the incident is a reportable breach, and if so, notification is due without unreasonable delay and no later than 60 days after discovery (45 CFR §164.400-414); that process runs in parallel with, not instead of, the insurance claim.\n\nWhy: A cyber insurance claim and a HIPAA breach notification obligation are separate legal tracks that both start from the same incident, and missing the breach-assessment track has its own deadline exposure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route to breach assessment before filing the claim.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Route to breach assessment before filing the claim",
          "why": "A cyber insurance claim and a HIPAA breach notification obligation are separate legal tracks that both start from the same incident, and missing the breach-assessment track has its own deadline exposure."
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Filing a property, business-interruption or cyber insurance claim after an incident — A flood, fire, theft, ransomware or closure event has caused a loss.",
      "title": "Filing a property, business-interruption or cyber insurance claim after an incident",
      "trigger": "A flood, fire, theft, ransomware or closure event has caused a loss",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "label": "The Dentist AI — How to approve protocols, the reviewer's guide (DOCS/PROTOCOLS/02_HOW_TO_APPROVE.md, F-2026-09-02-AG): two queues, the licence check, the four gestures, dwell floor, reason chips, audit-logged badge",
          "source": "The Dentist AI — How to approve protocols, the reviewer's guide (DOCS/PROTOCOLS/02_HOW_TO_APPROVE.md, F-2026-09-02-AG)",
          "url": "https://thedentist.ai/command/hitl-rounds/"
        },
        {
          "label": "HITL Rounds SSOT (DOCS/HITL_ROUNDS/00_SSOT.md §3 physics contract, §10 honesty walls): licensed dwell floor 1400 ms non-negotiable; a verdict the server refuses is never armed; the audit row is the review record",
          "source": "HITL Rounds SSOT (DOCS/HITL_ROUNDS/00_SSOT.md §3, §10)"
        },
        {
          "label": "California Health & Safety Code §1339.75 (AB 3030): generative-AI patient communications are exempt from the disclosure requirement when a licensed provider reviews them first — the legal reason a licensed review is a real act, not a formality",
          "source": "California Health & Safety Code §1339.75 (AB 3030)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=1339.75"
        }
      ],
      "class": "compliance-program-administration",
      "department": "management",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "cpa-023",
      "kind": "compliance",
      "materials": [
        "HITL Rounds deck at /command/hitl-rounds/ (founder) or the Practice Suite #hitl (reviewer)",
        "a minted reviewer identity with licence number on record",
        "the protocol runner at /for-dentists/protocols/#<id>"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Clinical and emergency protocols sit on the licensed lane and may be decided only by a licence-verified dentist at doctor rank. Front-office, HR, OSHA, HIPAA, marketing, finance, facility, IT and management protocols sit on the operations lane and may be decided by practice rank or above, no licence required. The lane is derived from the protocol's kind, never from anything the record says about itself, and a decision recorded on the wrong lane is ignored by construction.\n\nWhy: an operations approval can never move a clinical protocol out of draft; checking the lane first prevents a decision that will not count.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm you are the right reviewer for this lane",
          "why": "an operations approval can never move a clinical protocol out of draft; checking the lane first prevents a decision that will not count."
        },
        {
          "detail": "Before the first decision, an admin mints a reviewer identity for you at /command/hitl/ (name, state licence number, licence state, role). An admin-key approval bypasses the licence check and is recorded as admin-token, which would put the words \"reviewed by a licensed dentist\" on a record with no licensed dentist in the audit trail. Do not use it for clinical protocols.\n\nWhy: the reviewed state is only as honest as the identity that signed it.",
          "gate": {
            "ack": "I am signed in as my own minted reviewer identity, with my licence number on the record, and not as the shared admin key.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Use your own minted reviewer identity, never the shared admin key",
          "why": "the reviewed state is only as honest as the identity that signed it."
        },
        {
          "detail": "On a licensed queue the approve gesture does not arm until you have opened the plain-language explainer of what this queue is, where the items come from, what you are being asked, and what a wrong call risks. This is deliberate and not skippable. The \"? Coach\" tutorial replays the four gestures at any time.\n\nWhy: consent to the stakes precedes the first verdict.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Open \"About this review\" once",
          "why": "consent to the stakes precedes the first verdict."
        },
        {
          "detail": "Each card shows the safety gates the protocol declares, the sources it cites as real links, its class, kind, version, roles and step count. If it declares no safety gates or cites no sources, the card says so in those words. Treat an absent gate list or an absent citation as a finding, not as blank space.\n\nWhy: you are certifying a procedure with its gates and its basis; a protocol with neither is usually a reject with a note.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Read the evidence the card carries",
          "why": "you are certifying a procedure with its gates and its basis; a protocol with neither is usually a reject with a note."
        },
        {
          "detail": "Swipe up (or click \"Open the deep surface\") to open the full protocol in the runner at /for-dentists/protocols/#<id>. Read every step, by the role each step names, as written. The card is a summary; the approval certifies the procedure, not the summary.\n\nWhy: an approval of version 1.0.0 blesses exactly that text, step by step.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Open the deep surface and read every step",
          "why": "an approval of version 1.0.0 blesses exactly that text, step by step."
        },
        {
          "detail": "Protocols converted from the harvest carry a needs_ack_review flag: the source had no acknowledgement text, so the converter inserted a neutral template (\"I confirm I have completed this step as written: …\"). Where a gate needs real language — a specific escalation instruction, a named threshold — the protocol must be rewritten before it is approved. Reject with a note that names the gate and the wording it needs.\n\nWhy: a generic acknowledgement on a safety gate is honest but not sufficient for a clinical sign-off.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Check acknowledgement wording on converted protocols",
          "why": "a generic acknowledgement on a safety gate is honest but not sufficient for a clinical sign-off."
        },
        {
          "detail": "Swipe right to approve (the draft label comes off), swipe left to reject (it stays a draft while it is rewritten), or swipe down to set it aside for later. A minimum dwell of 1.4 seconds per card must pass before a positive verdict can be committed; reduced-motion settings remove the animation but never the hold.",
          "forks": [
            {
              "goto": "s8",
              "id": "approve",
              "label": "Approve — the procedure is correct as written, step by step, with its gates and sources"
            },
            {
              "goto": "s8",
              "id": "reject",
              "label": "Reject — it needs a rewrite (wrong step, missing gate, missing source, generic ack wording, or a legal question you cannot settle)"
            },
            {
              "goto": "s10",
              "id": "set-aside",
              "label": "Set aside — nothing is recorded; the card returns to the queue oldest-first"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide"
        },
        {
          "detail": "A reason chip is required on every verdict, approve as well as reject. A rejection on a licensed queue also requires a written note that says what must change. If an operations protocol turns on a legal question you cannot settle (an OSHA or HIPAA detail, a state-board rule), reject it with a note rather than approving it as close enough.\n\nWhy: the reason is what the next reviewer, the author and an auditor read; a verdict without one is a tap, not a review.",
          "gate": {
            "ack": "I have recorded a reason for this verdict, and a written note if it is a rejection on a licensed queue.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Give the reason",
          "why": "the reason is what the next reviewer, the author and an auditor read; a verdict without one is a tap, not a review."
        },
        {
          "detail": "After the gesture, the card shows an \"audit-logged\" badge. The audit row is the review record: if the badge is absent, the insert failed, nothing changed and the protocol is still queued — decide it again. If a card refuses to commit, its version moved on since it was rendered (a redeploy); reload, because the new version is a new review. A 403 hitl_role_denied means the identity is below the queue's bar, is the item's author, or is a doctor whose licence is not verified.\n\nWhy: a decision that did not reach the audit trail did not happen.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the decision stuck",
          "why": "a decision that did not reach the audit trail did not happen."
        },
        {
          "detail": "The reviewed state is computed from your decision row; it is not a field anyone can write, so an author can never mark their own work reviewed. Editing a protocol un-approves it: a version bump returns it to the queue, and an approval of 1.0.0 never blesses edited 1.1.0 content. Once the signed-ratification layer ships (PROT-028), each approval also produces a hash and a public verify link; until then the audit row is the only proof. If the queue reads empty while protocols are still drafts, the decision trail could not be read and the queue lists nothing rather than re-presenting approved items — check the API rather than assuming you are finished.\n\nWhy: the moat is the signature, not the text; this step is what a copy of the library cannot reproduce.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Know what the approval now means, and what un-does it",
          "why": "the moat is the signature, not the text; this step is what a copy of the library cannot reproduce."
        }
      ],
      "subclass": "compliance-program-administration-and-legal-events",
      "summary": "Ratifying a protocol — a licensed dentist (clinical lane) or an operations reviewer (operations lane) reads a draft protocol in full and records an approve or reject decision in HITL Rounds. The reviewed state is computed from that decision row; nothing else can remove the draft label. This protocol is itself ratified by the same round.",
      "title": "Ratifying a protocol: the review round that takes a draft label off",
      "trigger": "A draft protocol is waiting in a HITL Rounds review queue (clinical lane or operations lane)",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        },
        {
          "kind": "generic",
          "label": "Validated sleep-disordered-breathing screening questionnaire — instrument licensing verified before any questionnaire text is embedded",
          "source": "Validated sleep-disordered-breathing screening questionnaire — instrument licensing verified before any questionnaire text is embedded"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "dsm-001",
      "kind": "clinical",
      "materials": [
        "validated sleep-disordered-breathing screening questionnaire",
        "airway/tongue-position visual scale reference",
        "tooth-wear (bruxism) charting form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Hygienist or dentist observes and charts risk signs during the exam: scalloped tongue, narrow palate, large tonsils, retrognathia, generalized tooth wear consistent with bruxism, and a thick or short neck.\n\nWhy: These are visible, low-cost proxies correlated with sleep-disordered breathing that a dental exam is well positioned to catch before a formal sleep study exists.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Note risk signs during the routine exam",
          "why": "These are visible, low-cost proxies correlated with sleep-disordered breathing that a dental exam is well positioned to catch before a formal sleep study exists."
        },
        {
          "detail": "Hygienist or dentist asks the patient (or a bed partner, if present) whether they snore, whether anyone has noticed pauses in breathing during sleep, and whether they feel excessively tired during the day.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Ask about snoring, witnessed pauses in breathing, and daytime fatigue"
        },
        {
          "detail": "Based on risk signs and symptom answers, decide whether a formal validated screening questionnaire should be completed at this visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "administer",
              "label": "One or more risk signs or symptoms present — administer the questionnaire"
            },
            {
              "goto": "s9",
              "id": "no-signs",
              "label": "No risk signs or symptoms present — no screen needed today"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether to administer the full screening questionnaire"
        },
        {
          "detail": "Patient completes the validated sleep-disordered-breathing screening questionnaire; hygienist or dentist scores it per the instrument's published scoring rule. The practice must select and configure a specific, appropriately licensed validated instrument and its published cutoff score under method_editable_fields before this step is usable — no instrument or threshold is named here because instrument licensing terms vary and must be verified first.\n\nWhy: A validated instrument, not free-text impressions, is what a referring physician expects to see attached to a referral.\n\nRecord: questionnaire responses and score in the chart",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Administer the validated screening questionnaire",
          "why": "A validated instrument, not free-text impressions, is what a referring physician expects to see attached to a referral."
        },
        {
          "detail": "Dentist reviews the questionnaire score together with the exam risk signs to decide whether the overall screen is positive.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "positive",
              "label": "Screen is positive — proceed to physician referral"
            },
            {
              "goto": "s10",
              "id": "negative",
              "label": "Screen is negative — no referral indicated today"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Review the questionnaire score with risk signs"
        },
        {
          "detail": "Dentist explains, in plain language, that the dental exam cannot diagnose sleep apnea — only a physician-ordered sleep study can — and that a referral will be offered.\n\nWhy: The dentist screens; only a physician diagnoses. Saying this out loud protects the patient from a false sense of diagnosis and keeps the practice inside its scope.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Note the positive screen and explain next steps to the patient",
          "why": "The dentist screens; only a physician diagnoses. Saying this out loud protects the patient from a false sense of diagnosis and keeps the practice inside its scope."
        },
        {
          "detail": "Record the questionnaire score, the risk signs observed, and that a physician referral will be initiated.\n\nRecord: screening result and referral intent in the chart",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Log the positive screen"
        },
        {
          "detail": "Screening complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Screening complete"
        },
        {
          "detail": "Record that no risk signs or symptoms were present and no questionnaire was administered at this visit.\n\nRecord: no-screen-indicated note in the chart",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Log that no screen was indicated"
        },
        {
          "detail": "Record the questionnaire score and that no referral is indicated at this time; note the recall interval to re-screen.\n\nRecord: negative screening result and re-screen interval in the chart",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Log the negative screen"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Sleep-disordered breathing screening at the dental exam — A patient reports snoring or fatigue, or shows airway, tongue or wear signs.",
      "title": "Sleep-disordered breathing screening at the dental exam",
      "trigger": "A patient reports snoring or fatigue, or shows airway, tongue or wear signs",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "dsm-002",
      "kind": "clinical",
      "materials": [
        "positive screening result summary",
        "sleep-medicine physician referral list",
        "referral letter template",
        "release-of-records form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Dentist confirms the screening questionnaire score and risk signs are documented before initiating the referral.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the positive screen is on file"
        },
        {
          "detail": "Front desk offers the patient a choice from the sleep-medicine physician referral list, or confirms the patient's own physician if they already have one.\n\nWhy: The dentist does not diagnose sleep apnea; a physician-ordered sleep study is required before any oral appliance can be prescribed.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Select a sleep-medicine physician from the referral list",
          "why": "The dentist does not diagnose sleep apnea; a physician-ordered sleep study is required before any oral appliance can be prescribed."
        },
        {
          "detail": "Patient signs a release-of-records authorization before the screening summary is sent to the selected physician.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Patient consent to release records to the physician.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "front-desk",
          "title": "Patient consent to release records to the physician"
        },
        {
          "detail": "Dentist completes the referral letter template with the screening result summary and the reason for referral (evaluation for sleep-disordered breathing and possible oral appliance candidacy).",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the referral letter"
        },
        {
          "detail": "The treating dentist signs the referral letter before it leaves the office.\n\nWhy: A referral for a diagnostic workup is a clinical communication and needs the treating dentist's own review, not a default send.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the referral letter before it is sent.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the referral letter before it is sent",
          "why": "A referral for a diagnostic workup is a clinical communication and needs the treating dentist's own review, not a default send."
        },
        {
          "detail": "Front desk sends the signed referral letter and released records to the selected sleep-medicine physician's office.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the referral to the physician"
        },
        {
          "detail": "Front office holds a follow-up task to check in with the patient and physician's office if no diagnosis or sleep-study result has been received within 6 weeks.",
          "id": "s7",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 3628800,
          "title": "Wait for the physician's diagnosis to come back"
        },
        {
          "detail": "Front desk checks whether the physician's diagnosis and, if applicable, a prescription for oral appliance therapy has arrived.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "received",
              "label": "Diagnosis and prescription received — log and route to candidacy check"
            },
            {
              "goto": "s11",
              "id": "not-received",
              "label": "Not yet received — follow up with patient and physician office"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "front-desk",
          "title": "Has a physician diagnosis and prescription for oral appliance therapy been received?"
        },
        {
          "detail": "File the physician's diagnosis report and any oral appliance therapy prescription in the chart.\n\nRecord: physician diagnosis and prescription in the chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log the diagnosis and prescription"
        },
        {
          "detail": "Referral cycle complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Referral cycle complete"
        },
        {
          "detail": "Front desk contacts the patient to confirm the sleep study was completed and calls the physician's office to request the report.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Follow up with the patient and the physician's office"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Physician referral for sleep testing and diagnosis — A positive screen; a sleep study and physician diagnosis are required before any appliance.",
      "title": "Physician referral for sleep testing and diagnosis",
      "trigger": "A positive screen; a sleep study and physician diagnosis are required before any appliance",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "dsm-003",
      "kind": "clinical",
      "materials": [
        "physician prescription for oral appliance therapy",
        "TMJ examination checklist",
        "periodontal chart",
        "dentition/restoration adequacy checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist reviews the physician's diagnosis and prescription for oral appliance therapy before beginning the candidacy exam.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the physician's prescription is on file"
        },
        {
          "detail": "Dentist checks jaw range of motion, joint sounds, palpation tenderness, and any history of TMJ disorder or recent jaw trauma.\n\nWhy: An oral appliance repositions the mandible nightly; unrecognized TMJ pathology is a common cause of appliance intolerance.\n\nRecord: TMJ examination findings in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the TMJ examination checklist",
          "why": "An oral appliance repositions the mandible nightly; unrecognized TMJ pathology is a common cause of appliance intolerance."
        },
        {
          "detail": "Dentist reviews the current periodontal chart, checking for active periodontal disease or tooth mobility that would affect appliance retention.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review periodontal status"
        },
        {
          "detail": "Dentist checks for a sufficient number of stable, sound teeth in each arch to retain an appliance, and notes any teeth needing treatment first.\n\nRecord: dentition and restoration adequacy findings in the chart",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Check dentition and restoration adequacy"
        },
        {
          "detail": "Based on the TMJ, periodontal and dentition findings, decide whether the patient is a candidate for oral appliance therapy as prescribed. This is the dentist's own determination, made before any sign-off — sign-off attests to the call just made, not a call not yet reached.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "cleared",
              "label": "Cleared — proceed to records and appliance order"
            },
            {
              "goto": "s9",
              "id": "conditional",
              "label": "Conditional — dental treatment needed before candidacy can be finalized"
            },
            {
              "goto": "s11",
              "id": "declined",
              "label": "Not a candidate — refer back to the physician for an alternative therapy"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Candidate for oral appliance therapy?"
        },
        {
          "detail": "The treating dentist signs off on the cleared candidacy determination just reached, before any appliance is ordered.\n\nWhy: Candidacy is a clinical judgment with downstream cost and lab-order consequences — it is never defaulted to yes, and sign-off attests to the specific determination made, not a determination still pending.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the cleared candidacy determination.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the cleared candidacy determination",
          "why": "Candidacy is a clinical judgment with downstream cost and lab-order consequences — it is never defaulted to yes, and sign-off attests to the specific determination made, not a determination still pending."
        },
        {
          "detail": "Record the candidacy determination as cleared, with the TMJ, periodontal and dentition findings supporting it.\n\nRecord: dental clearance determination in the chart",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Log dental clearance"
        },
        {
          "detail": "Candidacy determination complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Candidacy determination complete"
        },
        {
          "detail": "The treating dentist signs off on the conditional candidacy determination and the prerequisite treatment plan just identified.\n\nWhy: A conditional call still commits the practice to a treatment-then-reassess path and needs the same sign-off as a cleared or declined call.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the conditional candidacy determination.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the conditional candidacy determination",
          "why": "A conditional call still commits the practice to a treatment-then-reassess path and needs the same sign-off as a cleared or declined call."
        },
        {
          "detail": "Record the specific dental treatment needed before candidacy can be finalized, and the plan to re-evaluate after it is complete.\n\nRecord: conditional clearance and prerequisite treatment plan in the chart",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Log conditional clearance and required treatment"
        },
        {
          "detail": "The treating dentist signs off on the declined candidacy determination before the referring physician is notified.\n\nWhy: A declined determination routes the patient's therapy decision back to the physician and needs the same explicit sign-off as a cleared call.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the declined candidacy determination.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the declined candidacy determination",
          "why": "A declined determination routes the patient's therapy decision back to the physician and needs the same explicit sign-off as a cleared call."
        },
        {
          "detail": "Record the reason candidacy was declined and that the referring physician will be notified so an alternative therapy can be considered.\n\nRecord: declined candidacy determination and physician notification in the chart",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Log declined candidacy and physician notification"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Oral appliance candidacy — dental clearance, TMJ, periodontal and dentition check — A physician prescription for oral appliance therapy is received.",
      "title": "Oral appliance candidacy — dental clearance, TMJ, periodontal and dentition check",
      "trigger": "A physician prescription for oral appliance therapy is received",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "per-patient",
      "id": "dsm-004",
      "kind": "clinical",
      "materials": [
        "digital scanner or impression material",
        "protrusive bite registration device",
        "appliance lab order form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist confirms the dental clearance determination is documented before taking records.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm cleared candidacy is on file"
        },
        {
          "detail": "Assistant captures a full-arch digital intraoral scan of both arches (or conventional impressions if no scanner is available).",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Capture a full-arch digital scan or take impressions"
        },
        {
          "detail": "Dentist takes the protrusive bite registration at the initial mandibular position specified for the ordered appliance, using the protrusive registration device.\n\nWhy: The protrusive position at delivery sets the starting point for titration; recording it accurately avoids an early remake.\n\nRecord: protrusive bite registration position in the chart",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Record the protrusive bite registration",
          "why": "The protrusive position at delivery sets the starting point for titration; recording it accurately avoids an early remake."
        },
        {
          "detail": "Dentist checks the scan for full-arch coverage and confirms the protrusive bite registration is stable and accurately captured.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "pass",
              "label": "Records complete and usable"
            },
            {
              "goto": "s2",
              "id": "retake",
              "label": "One or more records need a retake"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Dentist reviews record quality before ordering"
        },
        {
          "detail": "Lab liaison completes the lab order form specifying the appliance type prescribed, protrusive position, and any patient-specific notes (e.g. tori, limited opening).",
          "id": "s5",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Complete the appliance lab order form"
        },
        {
          "detail": "Lab liaison sends the scan or impressions, bite registration, and completed order form to the appliance lab.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send the records and order to the lab"
        },
        {
          "detail": "Record the date records and the order were sent, and the expected turnaround time.\n\nRecord: lab order date and expected turnaround in the chart",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the lab order"
        },
        {
          "detail": "Records captured and lab order sent",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Records captured and lab order sent"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Oral appliance records — scans or impressions and protrusive bite registration — The candidate is cleared and the appliance is ordered.",
      "title": "Oral appliance records — scans or impressions and protrusive bite registration",
      "trigger": "The candidate is cleared and the appliance is ordered",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "dsm-005",
      "kind": "clinical",
      "materials": [
        "completed oral appliance",
        "fit and retention checklist",
        "titration schedule handout",
        "appliance care and cleaning instructions"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Assistant checks the returned appliance against the original lab order for appliance type and the protrusive position specified.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Verify the appliance against the lab order"
        },
        {
          "detail": "Dentist seats the appliance in the patient's mouth and checks the fit and retention checklist: full seating on all teeth, no rocking, no soft-tissue impingement, comfortable retention.\n\nRecord: fit and retention checklist results in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the appliance and check fit and retention"
        },
        {
          "detail": "Dentist decides whether the fit is acceptable to proceed with delivery, or whether an adjustment or remake is needed.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "acceptable",
              "label": "Fit is acceptable — proceed with delivery"
            },
            {
              "goto": "s2",
              "id": "adjust",
              "label": "Minor adjustment needed — adjust chairside and re-check"
            },
            {
              "goto": "s11",
              "id": "remake",
              "label": "Fit is unusable — return to lab for remake"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Fit acceptable to proceed?"
        },
        {
          "detail": "Dentist checks that the bite feels balanced with the appliance seated and there is no unexpected posterior open bite beyond what is expected for the appliance design.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Check the bite with the appliance in place"
        },
        {
          "detail": "Dentist explains, in plain language, that the appliance will be advanced gradually over the coming weeks per the titration schedule to find the position that resolves symptoms without discomfort, and gives the patient the titration schedule handout.\n\nWhy: Delivery is the start of titration, not the end of treatment — the patient needs to understand the appliance will change over time.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the titration schedule to the patient",
          "why": "Delivery is the start of titration, not the end of treatment — the patient needs to understand the appliance will change over time."
        },
        {
          "detail": "Assistant reviews daily cleaning, storage, and handling instructions with the patient, including when to call the office about a problem.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Give appliance care and cleaning instructions"
        },
        {
          "detail": "Patient signs acknowledgment that they received the appliance, the titration schedule, and the care instructions, and understand how to reach the office with concerns.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Patient acknowledgment of the delivery and titration plan.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Patient acknowledgment of the delivery and titration plan"
        },
        {
          "detail": "Front-office schedules the patient's first titration follow-up visit per the titration schedule interval.\n\nWhy: Generic functional equivalent of a front-office scheduling task — no vendor scheduling system is assumed.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the first titration follow-up",
          "why": "Generic functional equivalent of a front-office scheduling task — no vendor scheduling system is assumed."
        },
        {
          "detail": "Record the appliance delivered, the initial titration setting, and the scheduled first follow-up date.\n\nRecord: delivery details and initial titration setting in the chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log the delivery visit"
        },
        {
          "detail": "Appliance delivered and titration plan started",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Appliance delivered and titration plan started"
        },
        {
          "detail": "Record the reason for the remake, return the appliance to the lab, and notify the patient of the revised delivery timeline.\n\nRecord: remake reason and revised timeline in the chart",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Log the remake and notify the patient"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Oral appliance delivery, fit and titration instructions — The appliance is returned from the lab.",
      "title": "Oral appliance delivery, fit and titration instructions",
      "trigger": "The appliance is returned from the lab",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "dsm-006",
      "kind": "clinical",
      "materials": [
        "titration progress log",
        "symptom-improvement questionnaire",
        "physician efficacy sleep test order request"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist reviews the titration progress log and asks the patient about snoring reduction, witnessed pauses, and daytime fatigue since the last adjustment.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review titration progress at the follow-up visit"
        },
        {
          "detail": "Patient completes the symptom-improvement questionnaire at this visit; dentist compares the score to the pre-treatment baseline.\n\nRecord: symptom-improvement questionnaire score in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Administer the symptom-improvement questionnaire"
        },
        {
          "detail": "Based on symptom improvement, comfort, and remaining appliance range, decide whether to advance the appliance further or consider titration complete.",
          "forks": [
            {
              "goto": "s10",
              "id": "continue",
              "label": "Continue titration — advance the appliance and schedule the next check"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "complete",
              "label": "Titration appears complete — refer for physician efficacy testing"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Continue titration or consider titration complete?"
        },
        {
          "detail": "Dentist prepares a request to the treating physician for a physician-ordered efficacy sleep test with the appliance at its final titrated position, since only a physician can order and interpret it.\n\nWhy: Confirming the appliance is actually resolving the diagnosed condition — not just that symptoms feel better — requires an objective physician-ordered test; the dentist does not interpret sleep-study data as a diagnosis.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the physician efficacy sleep test order request",
          "why": "Confirming the appliance is actually resolving the diagnosed condition — not just that symptoms feel better — requires an objective physician-ordered test; the dentist does not interpret sleep-study data as a diagnosis."
        },
        {
          "detail": "The treating dentist signs the efficacy-test request before it is sent to the physician.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the efficacy-test request before it is sent.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the efficacy-test request before it is sent"
        },
        {
          "detail": "Front desk sends the signed efficacy-test request and the final titration position to the treating physician's office.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the efficacy-test request to the physician"
        },
        {
          "detail": "Front office holds a follow-up task to check in with the physician's office if no efficacy result has been received within 2 weeks.",
          "id": "s7",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1209600,
          "title": "Wait for the physician's efficacy-test result"
        },
        {
          "detail": "File the physician's efficacy-test result and any further instructions from the physician in the chart.\n\nRecord: physician efficacy-test result in the chart",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Log the physician's efficacy-test outcome"
        },
        {
          "detail": "Follow-up and efficacy coordination complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Follow-up and efficacy coordination complete"
        },
        {
          "detail": "Dentist advances the appliance per the titration schedule increment and front-office schedules the next follow-up visit.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Advance the appliance and schedule the next follow-up"
        },
        {
          "detail": "Record the new titration setting and the date of the next scheduled follow-up.\n\nRecord: titration setting and next follow-up date in the chart",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Log the titration step"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Follow-up visits and physician-ordered efficacy sleep test coordination — Titration is complete; efficacy must be verified by the treating physician.",
      "title": "Follow-up visits and physician-ordered efficacy sleep test coordination",
      "trigger": "Titration is complete; efficacy must be verified by the treating physician",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "dsm-007",
      "kind": "clinical",
      "materials": [
        "side-effect intake checklist",
        "morning repositioning exercise handout",
        "bite-change comparison records (pre-treatment models or photos)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist asks the patient to describe the symptom (bite change, jaw pain, excess salivation, tooth soreness), when it started, and whether it is present all day or only on waking.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Intake the side-effect report"
        },
        {
          "detail": "Dentist checks jaw range of motion and joint tenderness, compares the current bite to pre-treatment records or photos, and checks for any new tooth mobility.\n\nRecord: focused exam findings in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Perform a focused clinical exam"
        },
        {
          "detail": "Based on the exam, decide whether the side effect is minor and self-limiting, needs an active management step, or requires pausing appliance use.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "minor",
              "label": "Minor and expected — reassure and give self-management guidance"
            },
            {
              "goto": "s7",
              "id": "active-management",
              "label": "Needs an active step — repositioning exercises, appliance adjustment, or reduced nightly wear"
            },
            {
              "goto": "s8",
              "id": "pause",
              "label": "Significant TMJ pain or bite change — pause appliance use pending re-evaluation"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess severity and decide the management path"
        },
        {
          "detail": "Dentist gives the patient the morning repositioning exercise handout and explains that mild morning bite change and salivation commonly settle within the first weeks of use, per the guideline cited below; if the dentist's own clinical judgment for this patient differs from that general expectation, the active-management path is used instead.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Give self-management guidance"
        },
        {
          "detail": "Record the reported symptom, exam findings, management path chosen, and any follow-up scheduled.\n\nRecord: side-effect report and management plan in the chart",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Log the side-effect report and management plan"
        },
        {
          "detail": "Side-effect management complete",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Side-effect management complete"
        },
        {
          "detail": "Dentist has the patient perform repositioning exercises during the visit, adjusts the appliance if indicated, or reduces the nightly wear schedule temporarily, and schedules a re-check.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Apply the active management step"
        },
        {
          "detail": "The treating dentist personally confirms the decision to pause the patient's appliance therapy before it is communicated to the patient and the treating physician.\n\nWhy: Pausing sleep-disordered-breathing therapy has a direct clinical consequence for the patient's underlying diagnosis and is never left to a default or a non-dentist decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before pausing therapy and notifying the physician.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before pausing therapy and notifying the physician",
          "why": "Pausing sleep-disordered-breathing therapy has a direct clinical consequence for the patient's underlying diagnosis and is never left to a default or a non-dentist decision."
        },
        {
          "detail": "Dentist instructs the patient to stop nightly appliance use until re-evaluated, and schedules a prompt follow-up visit.\n\nWhy: Significant, persistent TMJ pain or a bite change that does not resolve on removal needs to be assessed before more nightly loading is added.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Pause appliance use and schedule re-evaluation",
          "why": "Significant, persistent TMJ pain or a bite change that does not resolve on removal needs to be assessed before more nightly loading is added."
        },
        {
          "detail": "Decide whether the pause in appliance use is significant enough to notify the treating physician, since it affects the patient's sleep-disordered-breathing treatment.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "notify",
              "label": "Notify the physician the appliance is paused"
            },
            {
              "goto": "s5",
              "id": "no-notify",
              "label": "Brief pause, physician notification not needed"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Notify the treating physician of the pause?"
        },
        {
          "detail": "Dentist or front desk sends a brief note to the treating physician that appliance use has been paused pending re-evaluation.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify the treating physician"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Side effects — bite change, TMJ discomfort, salivation, tooth movement — A patient reports a morning bite change or jaw pain from the appliance.",
      "title": "Side effects — bite change, TMJ discomfort, salivation, tooth movement",
      "trigger": "A patient reports a morning bite change or jaw pain from the appliance",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "annual",
      "id": "dsm-008",
      "kind": "clinical",
      "materials": [
        "annual appliance maintenance checklist",
        "wear and fit inspection checklist",
        "physician progress report template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Front desk schedules the patient's annual oral appliance maintenance visit at the 12-month mark, or on a physician's request for a status letter.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the annual maintenance visit"
        },
        {
          "detail": "Dentist checks the appliance for material wear, cracking, clasp integrity, and confirms it still seats and retains as expected.\n\nRecord: appliance wear and fit inspection findings in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Inspect the appliance for wear and fit"
        },
        {
          "detail": "Dentist asks the patient about current snoring, fatigue, and nightly appliance use, comparing to the last documented status.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Reassess symptoms and adherence"
        },
        {
          "detail": "Dentist checks the bite, periodontal status, and tooth position for any appliance-related changes since the last annual visit.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Check oral health for appliance-related changes"
        },
        {
          "detail": "Based on the inspection and reassessment, decide whether the appliance can continue in service as-is, needs repair, or needs replacement.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "continue",
              "label": "Appliance and oral health stable — continue as-is"
            },
            {
              "goto": "s11",
              "id": "repair",
              "label": "Appliance needs repair"
            },
            {
              "goto": "s12",
              "id": "replace",
              "label": "Appliance needs replacement — new records required"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Determine outcome of the annual check"
        },
        {
          "detail": "Dentist completes the physician progress report template summarizing appliance condition, symptom status, and adherence since the last report.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the physician progress report"
        },
        {
          "detail": "The treating dentist signs the physician progress report before it is sent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the progress report before it is sent.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the progress report before it is sent"
        },
        {
          "detail": "Front desk sends the signed physician progress report to the patient's treating physician.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the progress report to the treating physician"
        },
        {
          "detail": "Record the maintenance decision, any repair or replacement arranged, and the date the physician report was sent.\n\nRecord: annual maintenance outcome and physician report date in the chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log the annual visit outcome"
        },
        {
          "detail": "Annual maintenance and physician report complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Annual maintenance and physician report complete"
        },
        {
          "detail": "Dentist sends the appliance to the lab for repair and schedules a return visit for re-delivery.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Arrange the appliance repair"
        },
        {
          "detail": "Dentist routes the patient back to the records step to begin a new appliance order.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Arrange for new records and a replacement appliance"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Annual appliance maintenance and physician progress report — 12 months since delivery, or the physician requests a status letter.",
      "title": "Annual appliance maintenance and physician progress report",
      "trigger": "12 months since delivery, or the physician requests a status letter",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "source": "American Academy of Dental Sleep Medicine — clinical resources and practice guidance for oral appliance therapy (openly published)",
          "url": "https://www.aadsm.org/"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "source": "American Academy of Sleep Medicine — clinical practice guidelines and standards (openly published)",
          "url": "https://aasm.org/"
        },
        {
          "kind": "generic",
          "label": "Validated sleep-disordered-breathing screening questionnaire — instrument licensing verified before any questionnaire text is embedded",
          "source": "Validated sleep-disordered-breathing screening questionnaire — instrument licensing verified before any questionnaire text is embedded"
        },
        {
          "kind": "open_standard",
          "label": "American Academy of Pediatric Dentistry policy on management of obstructive sleep apnea and airway in children (openly published)",
          "source": "American Academy of Pediatric Dentistry policy on management of obstructive sleep apnea and airway in children (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        }
      ],
      "class": "dental-sleep-medicine",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "dsm-009",
      "kind": "clinical",
      "materials": [
        "intraoral camera or mirror",
        "tonsil/airway visual grading reference chart",
        "validated pediatric sleep-disordered-breathing screening questionnaire (instrument licensing verified before use)",
        "caregiver intake form",
        "physician/ENT referral form",
        "growth chart or existing chart data"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "caregiver",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "During cleaning and exam, look for and note: chronic mouth breathing, enlarged tonsils visible on mirror/camera exam, narrow or high-arched palate, dental crowding, tongue-tie, dark circles under the eyes, or a habitually open-mouth resting posture.\n\nWhy: Dentists and hygienists routinely see the oral cavity at intervals pediatricians do not, making the recall visit a practical screening opportunity for airway issues that affect growth, sleep and behavior.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Observe and note airway signs during the recall exam",
          "why": "Dentists and hygienists routinely see the oral cavity at intervals pediatricians do not, making the recall visit a practical screening opportunity for airway issues that affect growth, sleep and behavior."
        },
        {
          "detail": "Ask the accompanying caregiver: does the child snore most nights, gasp or pause breathing during sleep, wet the bed past the expected age, have daytime sleepiness or attention/behavior concerns, or sleep with the mouth open? Record answers as reported, not diagnosed.\n\nWhy: Snoring, apneic pauses, enuresis and daytime inattention are documented pediatric red flags for sleep-disordered breathing beyond what a purely visual exam can catch.\n\nRecord: caregiver-reported symptom checklist answers in the chart",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Ask the caregiver a brief symptom checklist",
          "why": "Snoring, apneic pauses, enuresis and daytime inattention are documented pediatric red flags for sleep-disordered breathing beyond what a purely visual exam can catch."
        },
        {
          "detail": "If any visual sign or caregiver-reported symptom is positive, have the caregiver complete the practice's validated pediatric sleep-disordered-breathing screening instrument (licensing/permission for the specific instrument verified before it is put into clinical use). Score per the instrument's published scoring rule. The practice must select and configure a specific, appropriately licensed validated pediatric instrument and its published cutoff score under method_editable_fields before this step is usable — no instrument or threshold is named here because instrument licensing terms vary and must be verified first.\n\nWhy: A validated instrument turns loose observations into a reproducible score the dentist can act on consistently across patients.\n\nRecord: questionnaire responses and score in the chart",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Administer the validated pediatric screening questionnaire when signs are present",
          "why": "A validated instrument turns loose observations into a reproducible score the dentist can act on consistently across patients."
        },
        {
          "detail": "The dentist reviews the visual findings, caregiver checklist and questionnaire score together.",
          "forks": [
            {
              "advised": false,
              "goto": "s15",
              "id": "negative",
              "label": "Screen negative — no significant signs or symptoms"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "positive",
              "label": "Screen positive — signs, symptoms or questionnaire score indicate risk"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the screen positive for airway/sleep-disordered-breathing risk?"
        },
        {
          "detail": "Tell the caregiver what was observed and why it is being flagged (e.g., 'your child's tonsils appear enlarged and you noted regular snoring — this pattern is worth having evaluated by a physician'). State clearly that the dentist does not diagnose sleep apnea; only a physician can order a sleep study and make that diagnosis.\n\nWhy: The dentist's role is screening and referral, not diagnosis — the language must not overstate what a dental screen can conclude.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the screening finding to the caregiver in plain, non-diagnostic language",
          "why": "The dentist's role is screening and referral, not diagnosis — the language must not overstate what a dental screen can conclude."
        },
        {
          "detail": "The accompanying caregiver or guardian signs a release-of-records authorization before the child's screening findings (visual observations, symptom checklist, questionnaire score) are sent outside the practice to a physician or ENT/sleep specialist.\n\nWhy: A minor's clinical findings never leave the practice without the caregiver's explicit authorization, mirroring the adult patient consent-to-release step used elsewhere in this class before any referral summary is sent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Caregiver consent to release the child's screening findings to the physician or ENT.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Caregiver consent to release the child's screening findings to the physician or ENT",
          "why": "A minor's clinical findings never leave the practice without the caregiver's explicit authorization, mirroring the adult patient consent-to-release step used elsewhere in this class before any referral summary is sent."
        },
        {
          "detail": "The treating dentist reviews and signs off on the screening findings and the recommendation to refer before any referral document leaves the practice — this is a clinical judgment step that never auto-submits.\n\nWhy: A referral implying a possible pediatric airway/sleep condition is a clinical recommendation and must carry a licensed provider's explicit review, not an automated pass-through.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed dentist sign-off before the referral is finalized.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed dentist sign-off before the referral is finalized",
          "why": "A referral implying a possible pediatric airway/sleep condition is a clinical recommendation and must carry a licensed provider's explicit review, not an automated pass-through."
        },
        {
          "detail": "Draft a referral letter summarizing the visual findings, caregiver-reported symptoms and questionnaire score, and route it to the family's pediatrician or, when the practice maintains a preferred network, directly to an ENT or pediatric sleep specialist. Generic functional equivalent — front-office referral routing follows the same shape used for other specialist-referral protocols in this practice.\n\nWhy: A concise, structured referral gives the receiving physician what they need to triage quickly instead of re-collecting the same history.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Prepare the referral letter to the physician or ENT/sleep specialist",
          "why": "A concise, structured referral gives the receiving physician what they need to triage quickly instead of re-collecting the same history."
        },
        {
          "detail": "Give the caregiver a printed or electronic copy of the referral, explain the physician will decide on any sleep study or diagnosis, and confirm the family's preferred contact method for the physician's office to reach them.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand the referral and instructions to the caregiver"
        },
        {
          "detail": "Enter the referral sent date, receiving physician or specialist, and a follow-up tracking flag into the front-desk referral log.\n\nRecord: Referral sent date, receiving physician/specialist, and follow-up tracking flag entered in the front-desk referral log.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the referral for tracking"
        },
        {
          "detail": "Hold the referral in the tracking log for about 30 days, checking whether the caregiver reports the appointment was scheduled or completed, or whether the physician's office sends back findings.\n\nWhy: Referrals that are never followed up on tend to be dropped by busy caregivers; a tracked wait window lets the practice proactively check in.",
          "id": "s11",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 2592000,
          "title": "Wait for caregiver follow-through or physician feedback (about 30 days)",
          "why": "Referrals that are never followed up on tend to be dropped by busy caregivers; a tracked wait window lets the practice proactively check in."
        },
        {
          "detail": "Did the caregiver follow through on the referral?",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "completed",
              "label": "Caregiver confirms the appointment happened or physician feedback received"
            },
            {
              "advised": false,
              "goto": "s17",
              "id": "no-response",
              "label": "No confirmation after the wait window"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the caregiver follow through on the referral?"
        },
        {
          "detail": "Enter whether the caregiver followed through and any physician feedback or diagnosis communication received into the chart and referral log.\n\nRecord: Whether the caregiver followed through, and any physician feedback or diagnosis communication received, entered in the chart and referral log.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Record the referral outcome in the chart"
        },
        {
          "detail": "Referral cycle complete",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Referral cycle complete"
        },
        {
          "detail": "Enter the negative airway screen result, findings reviewed, and the recall interval for the next re-screen into the chart.\n\nRecord: Negative airway screen result, findings reviewed, and the recall interval for re-screening, entered in the chart.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Document the negative screen and set the next recall re-screen"
        },
        {
          "detail": "Screening complete — no referral needed at this visit",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Screening complete — no referral needed at this visit"
        },
        {
          "detail": "Contact the caregiver by the confirmed method to check on the referral status and offer to resend the referral or answer scheduling questions.",
          "id": "s17",
          "kind": "step",
          "role": "front-desk",
          "title": "Reach out to the caregiver to encourage follow-through"
        }
      ],
      "subclass": "dental-sleep-medicine-and-oral-appliance-therapy",
      "summary": "Pediatric airway screening (mouth breathing, tonsils, enuresis) and referral — A child shows airway signs at a recall visit.",
      "title": "Pediatric airway screening (mouth breathing, tonsils, enuresis) and referral",
      "trigger": "A child shows airway signs at a recall visit",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "label": "Guidelines for Teaching the Comprehensive Control of Anxiety and Pain in Dentistry — Medical Emergency Preparedness",
          "source": "American Dental Association Council on Dental Education and Licensure",
          "url": "https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/anesthesia-and-emergency-medicine"
        },
        {
          "label": "Dental Board of California — Minimal, Moderate, and Deep Sedation and General Anesthesia Permit requirements (office emergency preparedness)",
          "source": "Dental Board of California",
          "url": "https://www.dbc.ca.gov/licensees/sedation.shtml"
        },
        {
          "label": "OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030 (post-event exposure and documentation requirements)",
          "source": "Occupational Safety and Health Administration",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        }
      ],
      "class": "medical-emergency-preparedness",
      "id": "emerg-syncope-response-protocol",
      "kind": "clinical",
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant",
        "front_desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "steps": [
        {
          "detail": "Before doing anything else: if the person is unresponsive AND not breathing normally, this is not a faint. Call emergency services (911) now, start the office's cardiac-arrest response and the AED/CPR protocol, and do not continue with this deck — this deck is for a fainting episode that resolves, and it is not a substitute for the office's emergency-response training or a licensed provider's own judgment.",
          "gate": {
            "ack": "I have checked responsiveness and breathing. If the person is unresponsive and not breathing normally, I am calling 911 and starting the office's cardiac-arrest response instead of continuing here.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Escalation gate — is this a faint, or a life threat?"
        },
        {
          "detail": "Watch for pallor, sweating, reported lightheadedness, dimming vision, or a sudden loss of muscle tone and consciousness in the chair. Note the time this was first noticed.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Recognize the signs"
        },
        {
          "detail": "Stop whatever procedure is underway, remove any instruments or materials from the mouth, and clear the immediate work area so the patient can be repositioned safely.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Stop treatment immediately"
        },
        {
          "detail": "Call out for the rest of the team by the office's agreed signal so additional hands, the emergency kit, and oxygen are brought to the room without the treating provider leaving the patient.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Call for team support"
        },
        {
          "detail": "Lower the chair so the patient is supine with the legs raised slightly above the level of the heart, which supports blood flow back to the brain in a simple faint.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Position the patient"
        },
        {
          "detail": "Check whether the patient responds to voice or a light touch, and watch the chest to confirm normal breathing. This assessment is what the opening escalation gate is asking about — if it changes here, stop and go back to the gate.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Assess responsiveness and breathing"
        },
        {
          "detail": "If the patient is not fully alert, use a head-tilt/chin-lift to keep the airway open and confirm nothing is obstructing it.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Open and maintain the airway"
        },
        {
          "detail": "Apply oxygen from the office's emergency kit per the equipment's normal operating instructions once the airway is open.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "portable oxygen tank and mask/cannula from the emergency kit"
          ],
          "role": "dentist",
          "title": "Give supplemental oxygen"
        },
        {
          "detail": "Check and record pulse, breathing rate, and blood pressure as soon as the emergency kit's monitoring equipment is in hand, and repeat at short intervals until the patient is stable.",
          "id": "s9",
          "kind": "step",
          "materials": [
            "blood pressure cuff",
            "pulse oximeter"
          ],
          "role": "dentist",
          "title": "Monitor vital signs"
        },
        {
          "detail": "Loosen a tight collar, tie, or belt if present, and keep the room well ventilated while the patient recovers.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Loosen restrictive clothing and ensure fresh air"
        },
        {
          "detail": "Reassess responsiveness, breathing, and vital signs after initial positioning and support. Most simple faints resolve within a few minutes of being positioned with legs raised.",
          "forks": [
            {
              "goto": "s12",
              "id": "recovers-quickly",
              "label": "Recovers within a short period"
            },
            {
              "goto": "s14",
              "id": "does-not-recover",
              "label": "Does not recover, or condition worsens"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient recover within a short period?"
        },
        {
          "detail": "Once alert and vital signs are stable, keep the patient reclined and monitored for several minutes before slowly returning the chair upright, watching for a repeat episode as position changes.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Recovery care"
        },
        {
          "detail": "Decide whether to resume, reschedule, or end the visit for the day based on how the patient is doing. Do not discharge the patient alone — arrange for someone to accompany them, and give simple aftercare guidance (rest, hydration, eating before the next visit).",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Decide on same-day treatment and safe discharge"
        },
        {
          "detail": "If the patient does not recover promptly, the condition worsens, or responsiveness/breathing become abnormal at any point, call emergency services (911) now and continue supportive care (airway, oxygen, monitoring, positioning) until they arrive. This is the same threshold as the opening gate — treat any doubt as a reason to escalate.",
          "gate": {
            "ack": "The patient has not recovered or has worsened. I am calling 911 now and continuing airway, oxygen, and monitoring support until emergency responders arrive.",
            "type": "safety"
          },
          "id": "s14",
          "kind": "gate",
          "role": "dentist",
          "title": "Escalate to emergency services"
        },
        {
          "detail": "When emergency responders arrive, give them a brief verbal summary: what was observed, when it started, what was done, and the most recent vital signs.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to emergency responders"
        },
        {
          "detail": "As soon as the immediate situation is resolved, write down what was observed, the timeline, the interventions performed, vital-sign readings, and the outcome, following the practice's incident-documentation process.",
          "id": "s16",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the event"
        },
        {
          "detail": "Check the emergency kit and oxygen supply used during the event, restock or replace anything used or expired, and confirm the kit is ready again before the next patient.",
          "id": "s17",
          "kind": "step",
          "materials": [
            "office emergency kit checklist"
          ],
          "role": "office-manager",
          "title": "Restock and check the emergency kit"
        },
        {
          "detail": "Hold a short team debrief on what happened and how the response went, and note anything to adjust in the office's emergency-preparedness training or equipment.",
          "id": "s18",
          "kind": "step",
          "role": "office-manager",
          "title": "Team debrief"
        }
      ],
      "summary": "Generic office response when a patient loses consciousness in the chair: recognize, stop treatment, position, assess, support, monitor, recover, and document — for a faint that resolves. Opens with an escalation gate to the office's cardiac-arrest response for anyone who is unresponsive and not breathing normally.",
      "title": "In-Office Response to Loss of Consciousness (Syncope)",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "endo-001",
      "kind": "clinical",
      "materials": [
        "cold test refrigerant (e.g., 1,1,1,2-tetrafluoroethane spray) on a cotton pellet",
        "electric pulp tester",
        "periapical radiograph and sensor/film",
        "cotton-tip applicators",
        "mirror and explorer",
        "chart odontogram"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask onset, duration, character (sharp/dull), what provokes it (hot/cold/biting/spontaneous), whether it lingers after the stimulus is removed, and whether it wakes the patient at night.\n\nWhy: Lingering pain after a stimulus and spontaneous night pain point toward irreversible pulpitis rather than reversible.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Record the chief complaint and pain history",
          "why": "Lingering pain after a stimulus and spontaneous night pain point toward irreversible pulpitis rather than reversible."
        },
        {
          "detail": "Use patient pointing, visual exam for caries/cracks/deep restorations, and a control (unaffected) tooth of similar type for comparison.\n\nWhy: Pulpal pain is often poorly localized by the patient; a control tooth calibrates the patient's response scale.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Localize the suspect tooth or teeth",
          "why": "Pulpal pain is often poorly localized by the patient; a control tooth calibrates the patient's response scale."
        },
        {
          "detail": "Isolate and dry the tooth, apply refrigerant on a cotton pellet to the mid-facial surface, and record whether there is a response, its intensity, and whether it lingers after the pellet is removed.\n\nWhy: Cold is the most reliable single chairside test for pulp vitality and reversible vs. irreversible pulpitis.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Perform the cold test",
          "why": "Cold is the most reliable single chairside test for pulp vitality and reversible vs. irreversible pulpitis."
        },
        {
          "detail": "Is the cold test result equivocal or is the tooth heavily restored/crowned?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "run-ept",
              "label": "Run the electric pulp test as well"
            },
            {
              "goto": "s7",
              "id": "skip-ept",
              "label": "Cold test result is clear — skip EPT"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the cold test result equivocal or is the tooth heavily restored/crowned?"
        },
        {
          "detail": "Does the patient have a cardiac pacemaker or implantable cardioverter-defibrillator (ICD)?\n\nWhy: Electric pulp testing passes electric current through the tooth, which can interfere with cardiac implantable devices; cold testing alone is used instead when a pacemaker or ICD is present.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-device",
              "label": "No known pacemaker or ICD"
            },
            {
              "goto": "s7",
              "id": "has-device",
              "label": "Yes — pacemaker or ICD present"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient have a cardiac pacemaker or implantable cardioverter-defibrillator (ICD)?",
          "why": "Electric pulp testing passes electric current through the tooth, which can interfere with cardiac implantable devices; cold testing alone is used instead when a pacemaker or ICD is present."
        },
        {
          "detail": "Isolate and dry the tooth, apply conducting medium and the tester tip to the mid-facial or incisal third, increase current gradually, and record the response relative to a control tooth.\n\nWhy: Electric pulp testing confirms vitality when cold-test findings are ambiguous, e.g. through full-coverage crowns.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Perform the electric pulp test",
          "why": "Electric pulp testing confirms vitality when cold-test findings are ambiguous, e.g. through full-coverage crowns."
        },
        {
          "detail": "Tap the tooth vertically and horizontally with a mirror handle and compare to adjacent teeth; palpate the buccal and lingual apex; have the patient bite on a stick/tab on each cusp to isolate a crack.\n\nWhy: Percussion and palpation localize periapical inflammation; bite testing isolates cracked-tooth pain the pulp tests will not show.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Percussion, palpation and bite testing",
          "why": "Percussion and palpation localize periapical inflammation; bite testing isolates cracked-tooth pain the pulp tests will not show."
        },
        {
          "detail": "Capture a periapical image showing the full root and 2–3mm of periapical bone; check for periapical radiolucency, widened periodontal ligament space, root resorption, or fracture lines.\n\nWhy: Radiographic findings correlate pulpal status with periapical bone changes and rule out non-endodontic sources.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Expose a periapical radiograph of the suspect tooth",
          "why": "Radiographic findings correlate pulpal status with periapical bone changes and rule out non-endodontic sources."
        },
        {
          "detail": "Combine history, cold/EPT response, percussion/palpation/bite results, and radiographic findings into a pulpal diagnosis (e.g., normal, reversible pulpitis, symptomatic/asymptomatic irreversible pulpitis, necrotic) and a periapical diagnosis (e.g., normal, symptomatic/asymptomatic apical periodontitis, acute/chronic apical abscess).\n\nRecord: Pulpal and periapical diagnosis entered in the chart with the supporting test findings",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Assemble pulpal and periapical diagnosis"
        },
        {
          "detail": "The treating dentist reviews and signs the pulpal and periapical diagnosis before it is used to plan or begin any treatment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the diagnosis before it drives treatment.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the diagnosis before it drives treatment"
        },
        {
          "detail": "What does the diagnosis indicate next?",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "endo-indicated",
              "label": "Endodontic treatment is indicated — proceed to case difficulty assessment"
            },
            {
              "goto": "s12",
              "id": "not-endo",
              "label": "Findings point to a non-endodontic cause — redirect workup"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "What does the diagnosis indicate next?"
        },
        {
          "detail": "Diagnosis complete and documented",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Diagnosis complete and documented"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Pulpal and periapical diagnosis — cold, electric pulp test, percussion, palpation, bite, periapical film — A patient reports tooth pain or a periapical radiolucency is found.",
      "title": "Pulpal and periapical diagnosis — cold, electric pulp test, percussion, palpation, bite, periapical film",
      "trigger": "A patient reports tooth pain or a periapical radiolucency is found",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE endodontic case difficulty assessment and referral standards",
          "source": "AAE endodontic case difficulty assessment and referral standards",
          "url": "https://www.aae.org/specialty/clinical-resources/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "endo-002",
      "kind": "clinical",
      "materials": [
        "case difficulty assessment form",
        "periapical and/or CBCT imaging",
        "referral form/letter"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull up the completed diagnostic workup, periapical film, and any additional imaging (e.g., CBCT if taken) for the tooth requiring treatment.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review the pulpal/periapical diagnosis and imaging"
        },
        {
          "detail": "Evaluate access/visibility, canal curvature and calcification, root/canal number and anatomy variation, prior treatment/restoration complexity, resorption, and medical/behavioral patient factors.\n\nWhy: A structured difficulty assessment reduces the chance of starting a case the practice cannot safely finish.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Score case difficulty factors",
          "why": "A structured difficulty assessment reduces the chance of starting a case the practice cannot safely finish."
        },
        {
          "detail": "Is this case within the practice's treat-in-house range?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "refer",
              "label": "High difficulty or complicating factors — refer to a specialist"
            },
            {
              "goto": "s9",
              "id": "treat",
              "label": "Moderate/low difficulty — treat in-house"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this case within the practice's treat-in-house range?"
        },
        {
          "detail": "Compile the diagnosis, imaging, relevant medical history, and reason for referral into a letter or portal submission to the specialist office.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Prepare the referral packet"
        },
        {
          "detail": "The referring dentist reviews and signs off on the referral packet before it is transmitted, confirming the diagnosis and reason for referral are accurate.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms referral before it is sent.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms referral before it is sent"
        },
        {
          "detail": "Transmit the referral packet to the specialist-referral office and give the patient the specialist's contact information and expected timing.",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Send referral to specialist and notify patient"
        },
        {
          "detail": "Record the referral date, receiving office, and reason in the patient's chart and treatment plan.\n\nRecord: Referral logged in chart with date, destination and reason",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Log the referral in the chart"
        },
        {
          "detail": "Treat-or-refer decision made and documented",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Treat-or-refer decision made and documented"
        },
        {
          "detail": "Select the appropriate in-house protocol (single-visit or multi-visit, anterior/premolar or molar) and schedule accordingly.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Plan in-house treatment"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Endodontic case difficulty assessment and refer-versus-treat decision — Endodontic treatment is indicated and the dentist must decide to treat or refer.",
      "title": "Endodontic case difficulty assessment and refer-versus-treat decision",
      "trigger": "Endodontic treatment is indicated and the dentist must decide to treat or refer",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "endo-003",
      "kind": "clinical",
      "materials": [
        "local anesthetic and syringe",
        "rubber dam kit",
        "high-speed handpiece and access burs",
        "irrigation syringe with 2.5-5.25% sodium hypochlorite",
        "cotton pellet and temporary restorative material",
        "periapical radiograph",
        "electronic apex locator",
        "paper points",
        "intracanal medicament (e.g., calcium hydroxide)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Call 911 immediately if the patient shows signs of airway compromise, difficulty swallowing, facial swelling extending to the eye or neck, fever with spreading swelling, or trouble breathing; do not begin any dental assessment or treatment until this is ruled out or EMS has responded.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 / activate EMS before any dental treatment if signs of a spreading or airway-threatening infection are present.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 / activate EMS before any dental treatment if signs of a spreading or airway-threatening infection are present"
        },
        {
          "detail": "Does the patient show signs of airway compromise, difficulty swallowing, facial swelling extending to the eye or neck, fever with spreading swelling, or trouble breathing?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "severe",
              "label": "Yes — signs of a spreading or airway-threatening infection"
            },
            {
              "goto": "s5",
              "id": "localized",
              "label": "No — localized tooth pain or swelling only"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient show signs of airway compromise, difficulty swallowing, facial swelling extending to the eye or neck, fever with spreading swelling, or trouble breathing?"
        },
        {
          "detail": "Call 911 immediately for any sign of airway compromise, spreading facial/neck swelling, difficulty breathing or swallowing, or high fever with systemic signs; do not begin dental treatment until EMS has assessed the patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 / activate EMS before anything else.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 / activate EMS before anything else"
        },
        {
          "detail": "Patient handed off to EMS; dental treatment paused",
          "id": "s4",
          "kind": "step",
          "role": "ems",
          "title": "Patient handed off to EMS; dental treatment paused"
        },
        {
          "detail": "Confirm symptomatic irreversible pulpitis or acute apical abscess using the diagnostic testing protocol findings already on the chart.\n\nWhy: Emergency pulp treatment is indicated by diagnosis, not by pain level alone.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the diagnosis supports emergency pulpal treatment",
          "why": "Emergency pulp treatment is indicated by diagnosis, not by pain level alone."
        },
        {
          "detail": "The treating dentist confirms the diagnosis and the plan to perform an emergency pulpotomy or pulpectomy before anesthesia is given.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before emergency pulpal treatment begins.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before emergency pulpal treatment begins"
        },
        {
          "detail": "Before anesthetic is given, screen for known drug/anesthetic allergies, current medications and anticoagulant use; if pulpectomy (canal instrumentation beyond the pulp chamber) is anticipated, confirm whether the patient has an AHA/ADA-recognized cardiac condition warranting antibiotic prophylaxis (e.g., prosthetic heart valve, prior infective endocarditis, certain congenital heart disease, cardiac transplant valvulopathy) and that premedication was taken as directed; also confirm no known latex allergy before rubber dam isolation is placed.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Screen medical history, allergies and cardiac premedication before anesthesia"
        },
        {
          "detail": "Administer local anesthetic appropriate to the tooth and confirm profound anesthesia (no response to cold/pulp testing or gentle probing) before proceeding.\n\nWhy: A hot tooth in acute irreversible pulpitis is notoriously hard to anesthetize; confirming profound anesthesia before instrumentation avoids a painful procedure.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Achieve profound local anesthesia",
          "why": "A hot tooth in acute irreversible pulpitis is notoriously hard to anesthetize; confirming profound anesthesia before instrumentation avoids a painful procedure."
        },
        {
          "detail": "Place the rubber dam, then open the access cavity to expose the pulp chamber roof and remove the coronal pulp.\n\nWhy: Rubber dam isolation prevents aspiration/ingestion of debris and irrigant and keeps the field free of saliva contamination.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Isolate with rubber dam and gain pulp chamber access",
          "why": "Rubber dam isolation prevents aspiration/ingestion of debris and irrigant and keeps the field free of saliva contamination."
        },
        {
          "detail": "Use an electronic apex locator combined with radiographic confirmation to establish working length for the canal(s) before extirpating pulp contents, to avoid over-instrumentation beyond the apex.\n\nWhy: Working length must be established before full canal extirpation; instrumenting to an unconfirmed length risks over-instrumentation and irrigant extrusion beyond the apex.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Determine working length before extirpation",
          "why": "Working length must be established before full canal extirpation; instrumenting to an unconfirmed length risks over-instrumentation and irrigant extrusion beyond the apex."
        },
        {
          "detail": "Pulpotomy (coronal pulp removal) or pulpectomy (full canal extirpation) today?",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "pulpectomy",
              "label": "Extirpate the full canal contents to working length today"
            },
            {
              "goto": "s12",
              "id": "pulpotomy",
              "label": "Remove coronal pulp only; complete canals at a follow-up visit"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Pulpotomy (coronal pulp removal) or pulpectomy (full canal extirpation) today?"
        },
        {
          "detail": "Irrigate the chamber and canal(s) with sodium hypochlorite, dry with paper points, and place an interim intracanal medicament if canals are not fully instrumented today.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Irrigate and place an interim medicament"
        },
        {
          "detail": "Seal the access opening with a temporary restorative material sufficient to prevent leakage until the next visit or final restoration.\n\nWhy: An unsealed access cavity allows bacterial re-entry and can cause the pain to return.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Place a temporary restoration",
          "why": "An unsealed access cavity allows bacterial re-entry and can cause the pain to return."
        },
        {
          "detail": "Explain expected soreness, over-the-counter pain management, signs that warrant a call back (increasing swelling, fever, spreading pain), and confirm the follow-up appointment.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Record diagnosis, anesthetic used, procedure performed (pulpotomy vs pulpectomy), medicament placed, and follow-up plan.\n\nRecord: Emergency pulp treatment note with diagnosis, procedure and follow-up plan",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Document the emergency visit"
        },
        {
          "detail": "Emergency pulpal treatment complete",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Emergency pulpal treatment complete"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Emergency pulpotomy or pulpectomy for irreversible pulpitis or acute apical abscess — A patient is in severe pain or has swelling from an endodontically involved tooth.",
      "title": "Emergency pulpotomy or pulpectomy for irreversible pulpitis or acute apical abscess",
      "trigger": "A patient is in severe pain or has swelling from an endodontically involved tooth",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "endo-004",
      "kind": "clinical",
      "materials": [
        "local anesthetic and syringe",
        "#11 or #15 scalpel blade and handle",
        "hemostat",
        "drain material (e.g., rubber dam strip) and suture for drain fixation",
        "irrigation syringe with saline",
        "gauze"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Call 911 immediately if there is any sign of airway compromise (difficulty breathing/swallowing, muffled voice, drooling), swelling extending into the floor of the mouth, neck, or toward the eye, trismus, or fever with rapidly spreading swelling; do not proceed with in-office drainage until this is ruled out.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Airway and systemic-spread check before any procedure.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Airway and systemic-spread check before any procedure"
        },
        {
          "detail": "Is the swelling localized and fluctuant with no airway/spread risk?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "refer-ems",
              "label": "Airway or spreading-infection risk present — activate EMS / refer to emergency department"
            },
            {
              "goto": "s5",
              "id": "proceed-local",
              "label": "Localized, fluctuant, no systemic risk — proceed with in-office I&D"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the swelling localized and fluctuant with no airway/spread risk?"
        },
        {
          "detail": "Call 911 or arrange immediate transport to an emergency department; provide the diagnosis and findings to the receiving team.",
          "id": "s3",
          "kind": "step",
          "role": "ems",
          "title": "Hand off to EMS or emergency department"
        },
        {
          "detail": "Patient escalated to emergency care; in-office I&D not performed",
          "id": "s4",
          "kind": "step",
          "role": "ems",
          "title": "Patient escalated to emergency care; in-office I&D not performed"
        },
        {
          "detail": "The treating dentist confirms the airway/spread screen is negative and it is safe to proceed with in-office incision and drainage before anesthetic is given.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before in-office incision and drainage.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before in-office incision and drainage"
        },
        {
          "detail": "Before anesthetic is given, screen for known drug/anesthetic allergies and current medications, including anticoagulant use, that could affect bleeding or anesthesia.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Screen medical history and allergies before anesthesia"
        },
        {
          "detail": "Achieve local anesthesia at the site, using a block or field block away from the most fluctuant/inflamed tissue where possible.\n\nWhy: Anesthetic injected directly into infected, acidic tissue is less effective and can spread infection.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Anesthetize the area",
          "why": "Anesthetic injected directly into infected, acidic tissue is less effective and can spread infection."
        },
        {
          "detail": "Make a small incision through the mucosa at the most fluctuant point of the swelling with a #11 or #15 blade.\n\nWhy: Incising at the dependent point allows gravity-assisted drainage and minimizes trauma.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Incise at the most dependent, fluctuant point",
          "why": "Incising at the dependent point allows gravity-assisted drainage and minimizes trauma."
        },
        {
          "detail": "Use a hemostat to gently open loculations within the abscess cavity and express pus; irrigate the cavity with saline.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Blunt-dissect and express purulent material"
        },
        {
          "detail": "Is the cavity large enough to benefit from a drain?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "place-drain",
              "label": "Place a drain and secure with a suture"
            },
            {
              "goto": "s12",
              "id": "no-drain",
              "label": "Small cavity — no drain needed"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the cavity large enough to benefit from a drain?"
        },
        {
          "detail": "Insert a small strip drain into the cavity and suture it in place; instruct the patient on drain care and removal timing.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Place and secure a drain"
        },
        {
          "detail": "Begin or plan definitive treatment of the causative tooth (pulpectomy, extraction, or referral) at this visit or a prompt follow-up.\n\nWhy: Drainage alone does not resolve the infection without treating or removing its source.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Address the odontogenic source",
          "why": "Drainage alone does not resolve the infection without treating or removing its source."
        },
        {
          "detail": "Prescribe antibiotics only if there are signs of a spreading infection (fever, cellulitis, lymphadenopathy) rather than for localized swelling alone, consistent with dental antibiotic stewardship guidance; document the guidance given, if any.\n\nWhy: Reserving antibiotics for signs of spreading infection rather than localized swelling alone aligns with dental antibiotic stewardship guidance.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Decide whether systemic antibiotics are indicated",
          "why": "Reserving antibiotics for signs of spreading infection rather than localized swelling alone aligns with dental antibiotic stewardship guidance."
        },
        {
          "detail": "Explain wound care, warm saline rinses, when to remove the drain, and specific signs that require an immediate call back or an ED visit (fever, spreading swelling, breathing difficulty).",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative and warning-sign instructions"
        },
        {
          "detail": "Record the airway assessment, incision location, findings, drain placement (if any), and follow-up plan.\n\nRecord: I&D procedure note including airway check, findings, and follow-up plan",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Document the incision and drainage"
        },
        {
          "detail": "Incision and drainage complete",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Incision and drainage complete"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Incision and drainage of a fluctuant odontogenic abscess with airway check — A localized fluctuant swelling with an endodontic or periodontal source.",
      "title": "Incision and drainage of a fluctuant odontogenic abscess with airway check",
      "trigger": "A localized fluctuant swelling with an endodontic or periodontal source",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 75,
      "frequency": "per-use",
      "id": "endo-005",
      "kind": "clinical",
      "materials": [
        "rubber dam kit",
        "local anesthetic and syringe",
        "high-speed and low-speed handpieces with access burs",
        "electronic apex locator",
        "rotary NiTi file system",
        "irrigation syringe with sodium hypochlorite and EDTA",
        "gutta percha points and sealer",
        "obturation heat source/plugger",
        "final restorative material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the informed consent conversation (diagnosis, procedure, risks, alternatives including no treatment, cost) has occurred and the consent form is signed before starting.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent obtained before treatment begins.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent obtained before treatment begins"
        },
        {
          "detail": "Before anesthetic is given, screen for known drug/anesthetic allergies and current medications, and confirm whether the patient has an AHA/ADA-recognized cardiac condition warranting antibiotic prophylaxis before endodontic instrumentation beyond the pulp chamber (e.g., prosthetic heart valve, prior infective endocarditis, certain congenital heart disease, cardiac transplant valvulopathy) and that premedication was taken as directed; also confirm no known latex allergy before rubber dam isolation.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Screen medical history, allergies and cardiac premedication before anesthesia"
        },
        {
          "detail": "Administer local anesthetic and confirm profound anesthesia before beginning access.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Achieve profound local anesthesia"
        },
        {
          "detail": "Place the rubber dam to isolate the tooth and create a clean, contamination-free field.\n\nWhy: Rubber dam isolation is standard of care for root canal treatment; it prevents saliva contamination and aspiration/ingestion of instruments or irrigants.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Isolate with rubber dam",
          "why": "Rubber dam isolation is standard of care for root canal treatment; it prevents saliva contamination and aspiration/ingestion of instruments or irrigants."
        },
        {
          "detail": "Remove all pulp chamber contents and identify all canal orifices.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Access opening"
        },
        {
          "detail": "Use an electronic apex locator combined with radiographic confirmation to establish working length approximately 0.5mm short of the apex.\n\nWhy: Working length short of the apical foramen limits over-instrumentation and irrigant extrusion.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Determine working length",
          "why": "Working length short of the apical foramen limits over-instrumentation and irrigant extrusion."
        },
        {
          "detail": "Use a crown-down technique with rotary NiTi files per the file system's sequence, recapitulating with hand K-files between rotary files to maintain patency.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Instrument and shape the canal(s)"
        },
        {
          "detail": "Irrigate with 2.5-5.25% sodium hypochlorite via a closed-ended needle with passive ultrasonic activation between files; finish with 17% EDTA for 1 minute, a final NaOCl flush, then saline, and dry the canal with paper points.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Irrigate throughout instrumentation and finish with a final rinse"
        },
        {
          "detail": "Fill the canal(s) with gutta percha and sealer using warm vertical condensation or a single-cone technique matched to the final file taper.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Obturate the canal(s)"
        },
        {
          "detail": "Confirm the obturation is within 0-2mm of the radiographic apex and document the finding.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Expose the final radiograph"
        },
        {
          "detail": "Schedule or place the definitive restoration; the tooth should be restored within 2 weeks because it is brittle without full-coverage or definitive restoration.\n\nWhy: A root-canal-treated tooth left unrestored is at high risk of fracture.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Plan the definitive restoration",
          "why": "A root-canal-treated tooth left unrestored is at high risk of fracture."
        },
        {
          "detail": "Explain expected soreness, pain management, and when to call back if pain or swelling worsens rather than improves.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Record anesthesia, working length, instrumentation and irrigation performed, obturation technique and materials, final radiograph finding, and restoration plan.\n\nRecord: Root canal treatment note with working length, obturation, final radiograph finding and restoration plan",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the completed procedure"
        },
        {
          "detail": "Non-surgical root canal treatment complete",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Non-surgical root canal treatment complete"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Non-surgical root canal treatment — anterior or premolar (single visit) — Diagnosis of irreversible pulpitis or necrosis in a single- or two-canal tooth.",
      "title": "Non-surgical root canal treatment — anterior or premolar (single visit)",
      "trigger": "Diagnosis of irreversible pulpitis or necrosis in a single- or two-canal tooth",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "per-use",
      "id": "endo-006",
      "kind": "clinical",
      "materials": [
        "rubber dam kit",
        "local anesthetic and syringe",
        "high-speed and low-speed handpieces with access burs",
        "electronic apex locator",
        "rotary NiTi file system",
        "irrigation syringe with sodium hypochlorite and EDTA",
        "intracanal medicament (e.g., calcium hydroxide)",
        "gutta percha points and sealer",
        "temporary and final restorative material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the informed consent conversation (diagnosis, one vs. two visit plan, risks, alternatives, cost) has occurred and the consent form is signed before starting.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent obtained before treatment begins.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent obtained before treatment begins"
        },
        {
          "detail": "Before anesthetic is given, screen for known drug/anesthetic allergies and current medications, and confirm whether the patient has an AHA/ADA-recognized cardiac condition warranting antibiotic prophylaxis before endodontic instrumentation beyond the pulp chamber (e.g., prosthetic heart valve, prior infective endocarditis, certain congenital heart disease, cardiac transplant valvulopathy) and that premedication was taken as directed; also confirm no known latex allergy before rubber dam isolation.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Screen medical history, allergies and cardiac premedication before anesthesia"
        },
        {
          "detail": "Administer local anesthetic, using supplemental techniques as needed for molars, and confirm profound anesthesia before beginning access.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Achieve profound local anesthesia"
        },
        {
          "detail": "Place the rubber dam to isolate the tooth and create a contamination-free field.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Isolate with rubber dam"
        },
        {
          "detail": "Remove all pulp chamber contents and locate all canal orifices, checking carefully for extra canals typical of molars (e.g., MB2).\n\nWhy: Missed canals are a leading cause of persistent symptoms after molar root canal treatment.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Access opening",
          "why": "Missed canals are a leading cause of persistent symptoms after molar root canal treatment."
        },
        {
          "detail": "Use an electronic apex locator combined with radiographic confirmation to establish working length for every canal, approximately 0.5mm short of the apex.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Determine working length for each canal"
        },
        {
          "detail": "Use a crown-down technique with rotary NiTi files per the file system's sequence, recapitulating with hand K-files between rotary files in each canal.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Instrument and shape each canal"
        },
        {
          "detail": "Irrigate with 2.5-5.25% sodium hypochlorite via a closed-ended needle with passive ultrasonic activation; finish with 17% EDTA for 1 minute, a final NaOCl flush, then saline, and dry the canals with paper points.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Irrigate throughout instrumentation and finish with a final rinse"
        },
        {
          "detail": "Complete obturation this visit or place an interim medicament and finish at a follow-up?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "interim",
              "label": "Place interim medicament and complete at a follow-up visit"
            },
            {
              "goto": "s14",
              "id": "single-visit",
              "label": "Canals are clean, dry and asymptomatic — obturate this visit"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Complete obturation this visit or place an interim medicament and finish at a follow-up?"
        },
        {
          "detail": "Place an intracanal medicament (e.g., calcium hydroxide) in each canal and seal the access opening with a temporary restorative material sufficient to prevent leakage until the next visit.\n\nWhy: An interim medicament helps disinfect the canal system between visits, especially for necrotic or symptomatic cases.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Place interim intracanal medicament and temporary seal",
          "why": "An interim medicament helps disinfect the canal system between visits, especially for necrotic or symptomatic cases."
        },
        {
          "detail": "Schedule the follow-up appointment to remove the medicament and complete obturation, typically within the interval the practice's protocol specifies.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the completion visit"
        },
        {
          "detail": "Record canals located, working lengths, medicament placed, and the plan for completion.\n\nRecord: Interim visit note with working lengths and medicament placed",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document the interim visit"
        },
        {
          "detail": "Non-surgical molar root canal treatment complete",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Non-surgical molar root canal treatment complete"
        },
        {
          "detail": "Fill each canal with gutta percha and sealer using warm vertical condensation or a single-cone technique matched to the final file taper.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Obturate all canals"
        },
        {
          "detail": "Confirm obturation of every canal is within 0-2mm of the radiographic apex and document the finding.",
          "id": "s15",
          "kind": "step",
          "role": "assistant",
          "title": "Expose the final radiograph"
        },
        {
          "detail": "Schedule or place the definitive restoration within 2 weeks; molars in particular need cuspal coverage given the extent of access preparation.",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Plan the definitive restoration"
        },
        {
          "detail": "Explain expected soreness, pain management, and when to call back if pain or swelling worsens.",
          "id": "s17",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Record instrumentation, obturation technique and materials, final radiograph findings, and restoration plan.\n\nRecord: Completed molar root canal treatment note with obturation and restoration plan",
          "id": "s18",
          "kind": "step",
          "role": "dentist",
          "title": "Document the completed procedure"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Non-surgical root canal treatment — molar (one or two visits with interim medicament) — Diagnosis of irreversible pulpitis or necrosis in a molar within general-practice difficulty range.",
      "title": "Non-surgical root canal treatment — molar (one or two visits with interim medicament)",
      "trigger": "Diagnosis of irreversible pulpitis or necrosis in a molar within general-practice difficulty range",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-use",
      "id": "endo-007",
      "kind": "clinical",
      "materials": [
        "electronic apex locator",
        "periapical radiograph/sensor",
        "rotary NiTi file system",
        "hand K-files for recapitulation",
        "irrigation syringe with sodium hypochlorite",
        "17% EDTA solution",
        "paper points"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Insert a small file into each canal to patency and record the electronic apex locator reading for each.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Establish an initial working length with the apex locator"
        },
        {
          "detail": "Expose a working-length radiograph with a file in place at the apex-locator reading and confirm the file tip sits approximately 0.5mm short of the radiographic apex.\n\nWhy: Apex locators can be misled by canal anatomy or moisture; radiographic confirmation is the second independent check.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm working length radiographically",
          "why": "Apex locators can be misled by canal anatomy or moisture; radiographic confirmation is the second independent check."
        },
        {
          "detail": "Do the apex-locator reading and radiograph agree within an acceptable margin?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "agree",
              "label": "Yes — proceed with instrumentation at the confirmed length"
            },
            {
              "goto": "s1",
              "id": "disagree",
              "label": "No — re-measure before proceeding"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Do the apex-locator reading and radiograph agree within an acceptable margin?"
        },
        {
          "detail": "Advance the first rotary NiTi file to the confirmed working length using the file system's crown-down sequence.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Instrument with the first rotary file to working length"
        },
        {
          "detail": "Deliver sodium hypochlorite via a closed-ended needle to at or near working length after each file, using passive ultrasonic activation to improve debridement.\n\nWhy: Irrigation between files clears debris the file has cut loose and keeps the canal disinfected throughout shaping.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Irrigate after each instrument",
          "why": "Irrigation between files clears debris the file has cut loose and keeps the canal disinfected throughout shaping."
        },
        {
          "detail": "Pass a small hand K-file to working length between rotary files to confirm patency and clear any debris blocking the apical portion of the canal.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Recapitulate with a hand K-file"
        },
        {
          "detail": "Is the canal fully shaped to the planned final file size?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "continue",
              "label": "No — continue with the next file in sequence"
            },
            {
              "goto": "s8",
              "id": "final-rinse",
              "label": "Yes — canal is at final shape, proceed to final rinse"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the canal fully shaped to the planned final file size?"
        },
        {
          "detail": "Irrigate with 17% EDTA for 1 minute to remove the smear layer, follow with a final sodium hypochlorite flush, then saline, and dry the canal with paper points.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the final irrigation sequence"
        },
        {
          "detail": "The treating dentist confirms working length, final shape and cleanliness of every canal before obturation proceeds.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off that canals are ready for obturation.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off that canals are ready for obturation"
        },
        {
          "detail": "Record the confirmed working length for each canal, final file size, and irrigation sequence completed.\n\nRecord: Working length and instrumentation checkpoint record per canal",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document working length and instrumentation checkpoints"
        },
        {
          "detail": "Canal(s) shaped, cleaned and dry — ready for obturation",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Canal(s) shaped, cleaned and dry — ready for obturation"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Working length, instrumentation and irrigation checkpoints — Access is complete and canals are located.",
      "title": "Working length, instrumentation and irrigation checkpoints",
      "trigger": "Access is complete and canals are located",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "per-use",
      "id": "endo-008",
      "kind": "clinical",
      "materials": [
        "gutta percha points matched to final file taper",
        "root canal sealer (e.g., epoxy resin-based)",
        "warm vertical condensation heat source and pluggers or single-cone technique instruments",
        "periapical radiograph/sensor",
        "temporary or definitive restorative material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the final irrigation sequence is complete and the canal is dried fully with paper points before selecting the master cone.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the canal is clean, shaped and dry"
        },
        {
          "detail": "Warm vertical condensation or single-cone technique?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "warm-vertical",
              "label": "Warm vertical condensation"
            },
            {
              "goto": "s3",
              "id": "single-cone",
              "label": "Single-cone technique with matched taper"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Warm vertical condensation or single-cone technique?"
        },
        {
          "detail": "Select a gutta percha cone matched to the final file taper and confirm tug-back fit at working length.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Select and fit the master gutta percha cone"
        },
        {
          "detail": "Coat the canal walls with sealer, seat the master cone, and complete filling using the chosen technique (warm vertical condensation or single-cone).",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Obturate the canal(s)"
        },
        {
          "detail": "Capture a periapical radiograph of the obturated tooth to confirm fill within 0-2mm of the radiographic apex, with no voids and appropriate density.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Expose the final radiograph"
        },
        {
          "detail": "Is the obturation acceptable on the final radiograph?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "acceptable",
              "label": "Yes — fill is within 0-2mm of the apex with adequate density"
            },
            {
              "goto": "s4",
              "id": "revise",
              "label": "No — under-filled, overextended, or voids present"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the obturation acceptable on the final radiograph?"
        },
        {
          "detail": "The treating dentist reviews the final radiograph and signs off that the obturation is acceptable before the access opening is sealed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the final obturation result.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the final obturation result"
        },
        {
          "detail": "Place a temporary or definitive restorative material over the access opening sufficient to prevent coronal leakage.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Seal the access opening"
        },
        {
          "detail": "Schedule the definitive full-coverage or core-and-crown restoration within 2 weeks of obturation, since the tooth is brittle without it.\n\nWhy: Delayed definitive restoration is a common preventable cause of post-endodontic fracture.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Schedule the definitive restoration",
          "why": "Delayed definitive restoration is a common preventable cause of post-endodontic fracture."
        },
        {
          "detail": "Explain to the patient why prompt restoration matters and confirm the scheduled date before they leave.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Communicate the restoration timeline to the patient"
        },
        {
          "detail": "Record the obturation technique and materials, final radiograph finding, and the scheduled restoration date.\n\nRecord: Obturation note with final radiograph finding and restoration date",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document obturation and restoration plan"
        },
        {
          "detail": "Obturation complete; restoration scheduled",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Obturation complete; restoration scheduled"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Obturation, final radiograph and definitive restoration timing — Canals are shaped, cleaned and dry.",
      "title": "Obturation, final radiograph and definitive restoration timing",
      "trigger": "Canals are shaped, cleaned and dry",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        },
        {
          "kind": "generic",
          "label": "AAE Endodontics: Colleagues for Excellence — Managing Sodium Hypochlorite Accidents",
          "source": "AAE Endodontics: Colleagues for Excellence — Managing Sodium Hypochlorite Accidents"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "endo-009",
      "kind": "clinical",
      "materials": [
        "closed-ended, side-vented irrigation needle",
        "ice packs",
        "sterile saline",
        "analgesics per office formulary",
        "camera for photographic documentation",
        "incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The instant the patient reports sudden severe pain, or swelling/bruising appears at the injection or treatment site during irrigation, stop irrigating, withdraw the needle from the canal, and set the syringe aside.\n\nWhy: Continued irrigation forces more hypochlorite into periapical tissue; the accident is a chemical injury, and stopping the source is the first move. This protocol is not entry-gated as a 911/EMS safety_gate because immediately stopping the irrigant source takes priority over any other action, including screening; airway assessment and 911 escalation still occur immediately after, at 'assess_airway'.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Stop irrigation immediately and remove the needle from the canal",
          "why": "Continued irrigation forces more hypochlorite into periapical tissue; the accident is a chemical injury, and stopping the source is the first move. This protocol is not entry-gated as a 911/EMS safety_gate because immediately stopping the irrigant source takes priority over any other action, including screening; airway assessment and 911 escalation still occur immediately after, at 'assess_airway'."
        },
        {
          "detail": "Check airway, breathing and extent of swelling",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "stable",
              "label": "Airway clear, swelling localized to the face or intraoral tissue"
            },
            {
              "goto": "s12",
              "id": "compromised",
              "label": "Airway compromise, rapid swelling spreading toward the neck/floor of mouth, or difficulty breathing"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Check airway, breathing and extent of swelling"
        },
        {
          "detail": "Irrigate the site copiously with sterile saline to dilute residual sodium hypochlorite, then apply extraoral ice packs in cycles (approximately 20 minutes on, 20 minutes off) for the first several hours.\n\nWhy: Dilution limits further tissue damage and ice reduces edema and hematoma formation.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Irrigate the area copiously with sterile saline",
          "why": "Dilution limits further tissue damage and ice reduces edema and hematoma formation."
        },
        {
          "detail": "Offer an appropriate analgesic per office formulary, explain in plain language what happened (an irrigant escaped the tooth into surrounding tissue), and what to expect over the following days.\n\nWhy: Sodium hypochlorite accidents are frightening; clear plain-language explanation reduces patient distress and supports informed consent for next steps.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Offer analgesia and reassure the patient",
          "why": "Sodium hypochlorite accidents are frightening; clear plain-language explanation reduces patient distress and supports informed consent for next steps."
        },
        {
          "detail": "Take dated photographs of the swelling/ecchymosis from at least two angles for the chart, with patient consent.\n\nWhy: Photographic baseline documents extent and supports monitoring resolution over the following days.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Photograph the affected area",
          "why": "Photographic baseline documents extent and supports monitoring resolution over the following days."
        },
        {
          "detail": "The treating dentist personally explains the incident, expected course, warning signs, and the follow-up plan to the patient before they leave, and answers questions.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed dentist discloses the incident to the patient before the visit ends.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed dentist discloses the incident to the patient before the visit ends"
        },
        {
          "detail": "Write a chart entry covering what occurred, the time, the immediate response taken, the photographs referenced, the disclosure conversation, and the follow-up plan, then complete a separate office incident-report form for risk management.\n\nRecord: Chart entry: what occurred, time, immediate response taken, photographs referenced, disclosure conversation, and the follow-up plan; a separate office incident-report form for risk-management purposes.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the incident in the chart and incident log"
        },
        {
          "detail": "Front desk schedules a callback within 24 hours and a follow-up visit within 2-3 days, and gives the patient a direct number to call sooner if swelling worsens, breathing changes, or fever develops.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule follow-up call and next-day check"
        },
        {
          "detail": "Track symptom resolution over the following 1-2 weeks; most sodium hypochlorite accidents resolve without permanent damage, but persistent paresthesia, tissue necrosis, or non-resolving swelling requires an oral surgery referral.",
          "id": "s9",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 1209600,
          "title": "Monitor for resolution over 1-2 weeks"
        },
        {
          "detail": "Resolving as expected, or refer for specialist evaluation?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "resolving",
              "label": "Swelling and bruising are resolving on the expected timeline"
            },
            {
              "goto": "s13",
              "id": "refer",
              "label": "Persistent paresthesia, tissue necrosis, or non-resolving symptoms"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Resolving as expected, or refer for specialist evaluation?"
        },
        {
          "detail": "Incident closed and documented",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Incident closed and documented"
        },
        {
          "detail": "Call 911 immediately. Keep the patient upright if breathing is labored, do not leave the patient alone, and have someone meet EMS at the door.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 for airway compromise or rapidly spreading swelling.",
            "type": "safety"
          },
          "id": "s12",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 for airway compromise or rapidly spreading swelling"
        },
        {
          "detail": "Send a written referral summarizing the incident, response taken, and current findings to an oral surgeon or endodontist for further evaluation and management.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to oral surgery or endodontic specialist"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Sodium hypochlorite extrusion accident response — Sudden severe pain, swelling or bruising during irrigation.",
      "title": "Sodium hypochlorite extrusion accident response",
      "trigger": "Sudden severe pain, swelling or bruising during irrigation",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "endo-010",
      "kind": "clinical",
      "materials": [
        "periapical radiograph or CBCT if available",
        "operating microscope if available",
        "mineral trioxide aggregate or equivalent repair material",
        "incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note tactile feedback (sudden loss of resistance, a file that stops advancing then will not retrieve, or unexpected bleeding suggesting a perforation) and stop instrumentation in that canal.\n\nWhy: Early recognition preserves the most treatment options; continued instrumentation risks pushing a separated fragment further apically or enlarging a perforation.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Recognize the separation or perforation as it occurs",
          "why": "Early recognition preserves the most treatment options; continued instrumentation risks pushing a separated fragment further apically or enlarging a perforation."
        },
        {
          "detail": "Take a periapical radiograph (and CBCT if available and indicated) to confirm and localize the separated instrument fragment or perforation site.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm with a radiograph"
        },
        {
          "detail": "Assess severity and whether it is manageable in-house",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "in-house",
              "label": "Fragment is bypassable/retrievable, or perforation is small and accessible with an operating microscope on hand"
            },
            {
              "goto": "s5",
              "id": "beyond-scope",
              "label": "Fragment is apical/non-retrievable, or perforation is large, subcrestal, or beyond the practice's equipment and skill"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess severity and whether it is manageable in-house"
        },
        {
          "detail": "Attempt bypass or retrieval of the fragment, or seal the perforation with an appropriate repair material, working within the dentist's training and available equipment.\n\nWhy: Only attempt what is within scope; over-reaching increases the chance of further complication.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Attempt in-house management",
          "why": "Only attempt what is within scope; over-reaching increases the chance of further complication."
        },
        {
          "detail": "The treating dentist reviews the radiograph and clinical findings and decides, before proceeding further, whether to complete treatment in-house or refer to an endodontist or oral surgeon.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed dentist decides refer versus continue treatment.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed dentist decides refer versus continue treatment"
        },
        {
          "detail": "Explain what happened, what it means for the tooth's prognosis, and the plan (in-house completion or referral), before the patient leaves that visit.\n\nWhy: Prompt, honest disclosure of a procedural complication is a professional and risk-management expectation, and supports informed consent for next steps.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Disclose the event to the patient in plain language",
          "why": "Prompt, honest disclosure of a procedural complication is a professional and risk-management expectation, and supports informed consent for next steps."
        },
        {
          "detail": "Write a chart entry describing the event, the radiographic findings, the management taken, the disclosure conversation, and the referral or continued-treatment plan, and complete the incident-report form for risk management.\n\nRecord: Chart entry describing the event, radiographic findings, management taken, disclosure conversation, and the referral or continued-treatment plan; incident-report form for risk management.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the event, radiographs and disclosure"
        },
        {
          "detail": "Before proceeding with either continued in-house treatment or referral, confirm the patient has been informed of the complication and the revised prognosis, and document that the patient agrees with the chosen path forward.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient consent for the chosen path forward.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm patient consent for the chosen path forward"
        },
        {
          "detail": "Route to referral or continued in-house treatment",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "continue",
              "label": "Continue and complete treatment in-house"
            },
            {
              "goto": "s11",
              "id": "refer-out",
              "label": "Refer to specialist"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Route to referral or continued in-house treatment"
        },
        {
          "detail": "Complication managed in-house and documented",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Complication managed in-house and documented"
        },
        {
          "detail": "Prepare a referral letter summarizing the event, radiographs, and management to date, and send it with the patient's records to an endodontist or oral surgeon per the specialist-referral role.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Send a written referral to the specialist"
        },
        {
          "detail": "Case referred and documented",
          "id": "s12",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Case referred and documented"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Separated instrument or perforation — management, disclosure and referral — A file separates or a perforation is created during treatment.",
      "title": "Separated instrument or perforation — management, disclosure and referral",
      "trigger": "A file separates or a perforation is created during treatment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "endo-011",
      "kind": "clinical",
      "materials": [
        "phone triage script",
        "periapical radiograph equipment",
        "local anesthetic and access instruments for emergency drainage",
        "analgesic and antibiotic formulary reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask which tooth was treated and when, the pain level (0-10), whether there is swelling, fever, or difficulty swallowing/breathing, and whether pain medication has been taken.\n\nWhy: A structured set of questions lets front desk triage severity consistently before the dentist is involved.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the call and gather symptom details",
          "why": "A structured set of questions lets front desk triage severity consistently before the dentist is involved."
        },
        {
          "detail": "If the patient reports difficulty breathing or swallowing, swelling extending toward the eye or down the neck, or a high fever, instruct them to call 911 or go to the emergency department now rather than waiting for an office appointment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Screen for a true emergency before scheduling.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "front-desk",
          "title": "Screen for a true emergency before scheduling"
        },
        {
          "detail": "Fit the patient into the schedule the same day if possible; relay the triage notes to the dentist before the visit.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer a same-day or next-available appointment"
        },
        {
          "detail": "Percuss and palpate the tooth, check for swelling and fluctuance, and take a new periapical radiograph to compare to the pre- and post-treatment films.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Clinically examine and radiograph the tooth"
        },
        {
          "detail": "Fluctuant swelling present requiring drainage?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-fluctuance",
              "label": "No fluctuant swelling — occlusal trauma or inflammatory flare-up"
            },
            {
              "goto": "s12",
              "id": "fluctuance",
              "label": "Fluctuant swelling present"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Fluctuant swelling present requiring drainage?"
        },
        {
          "detail": "Lightly relieve the tooth out of occlusion with articulating paper, confirm the temporary or permanent restoration is intact and well-sealed, and reassure the patient that some post-treatment discomfort is expected.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Relieve occlusion and recheck the seal"
        },
        {
          "detail": "The treating dentist reviews the exam findings and confirms the management performed and any medication guidance before it is communicated and, if applicable, before any prescription is called in.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating dentist confirms the management and prescribing plan before it is given to the patient.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating dentist confirms the management and prescribing plan before it is given to the patient"
        },
        {
          "detail": "Advise on analgesic dosing per the office formulary; prescribe antibiotics only if there are signs of a spreading infection (fever, cellulitis, lymphadenopathy) rather than for pain alone.\n\nWhy: Reserving antibiotics for signs of spreading infection rather than pain aligns with dental antibiotic stewardship guidance.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Provide pain-control and, if indicated, antibiotic guidance",
          "why": "Reserving antibiotics for signs of spreading infection rather than pain aligns with dental antibiotic stewardship guidance."
        },
        {
          "detail": "Write a chart entry noting the symptoms reported, the exam and radiographic findings, the management performed (relief, drainage, or medication), and the follow-up instructions given.\n\nRecord: Chart entry noting symptoms reported, exam and radiographic findings, management performed (relief, drainage, medication), and follow-up instructions given.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the flare-up visit"
        },
        {
          "detail": "Front desk schedules a callback within 24-48 hours to confirm symptoms are improving, and flags the chart for the dentist to review if the patient does not answer.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up callback"
        },
        {
          "detail": "Flare-up managed and follow-up scheduled",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Flare-up managed and follow-up scheduled"
        },
        {
          "detail": "If the tooth is accessible, reopen through the existing access to allow drainage; if a soft-tissue fluctuant swelling is present, incise and drain following standard technique.\n\nWhy: Draining relieves pressure that is the primary source of a flare-up's pain and reduces the risk of spreading infection.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Reopen access or incise and drain as indicated",
          "why": "Draining relieves pressure that is the primary source of a flare-up's pain and reduces the risk of spreading infection."
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Post-endodontic flare-up management — A patient calls with severe pain or swelling one to three days after endodontic treatment.",
      "title": "Post-endodontic flare-up management",
      "trigger": "A patient calls with severe pain or swelling one to three days after endodontic treatment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "endo-012",
      "kind": "clinical",
      "materials": [
        "current and prior periapical radiographs",
        "CBCT if available",
        "periodontal probe",
        "treatment options handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note persistent or new symptoms, a periapical radiolucency that is new, enlarging, or not resolving, or a sinus tract, on a tooth with existing root canal treatment.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify signs of a failing previously treated tooth"
        },
        {
          "detail": "Check remaining tooth structure and ferrule, crown-to-root ratio, periodontal probing depths and mobility, and root fracture signs (radiographic J-shaped lesion, deep isolated pocket).\n\nWhy: A tooth with poor restorability or periodontal support may not be worth retreating regardless of the endodontic prognosis.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Assess restorability and periodontal status",
          "why": "A tooth with poor restorability or periodontal support may not be worth retreating regardless of the endodontic prognosis."
        },
        {
          "detail": "Is the tooth restorable and periodontally sound enough to save?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "restorable",
              "label": "Restorable with adequate periodontal support"
            },
            {
              "goto": "s9",
              "id": "not-restorable",
              "label": "Not restorable, vertical root fracture suspected, or inadequate periodontal support"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the tooth restorable and periodontally sound enough to save?"
        },
        {
          "detail": "Choose retreatment approach or refer",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "nonsurgical-retreat",
              "label": "Non-surgical retreatment feasible in-house or in-scope"
            },
            {
              "goto": "s10",
              "id": "surgical-or-complex",
              "label": "Apical surgery indicated, or case complexity is beyond scope"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Choose retreatment approach or refer"
        },
        {
          "detail": "Present retreatment, apical surgery, extraction with replacement, and no-treatment-with-monitoring as options, with the prognosis, risks and approximate cost of each, and let the patient choose.\n\nWhy: A tooth with a failed prior treatment carries a materially different prognosis than a virgin case; the patient needs that context to consent meaningfully.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss options, prognosis and cost with the patient",
          "why": "A tooth with a failed prior treatment carries a materially different prognosis than a virgin case; the patient needs that context to consent meaningfully."
        },
        {
          "detail": "Record the patient's chosen option and confirm informed consent, including that they understood the alternatives, before scheduling treatment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Document informed consent for the chosen path.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Document informed consent for the chosen path"
        },
        {
          "detail": "Write a chart entry with the restorability and periodontal findings, the options presented to the patient, the patient's chosen path, and the documented consent.\n\nRecord: Chart entry with restorability/periodontal findings, options presented, patient's chosen path, and consent.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the assessment and chosen plan"
        },
        {
          "detail": "Retreatment-versus-extraction decision documented",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Retreatment-versus-extraction decision documented"
        },
        {
          "detail": "Explain why the tooth is not salvageable and present replacement options (implant, bridge, partial denture, or no replacement) with approximate cost and timeline.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss extraction and replacement options"
        },
        {
          "detail": "Send a referral letter with current and historical radiographs summarizing findings and prior treatment to a specialist per the specialist-referral role.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to an endodontist for surgical or complex retreatment"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Failed root canal — retreatment, apical surgery or extraction decision — Persistent symptoms or a periapical lesion on a previously treated tooth.",
      "title": "Failed root canal — retreatment, apical surgery or extraction decision",
      "trigger": "Persistent symptoms or a periapical lesion on a previously treated tooth",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "endo-013",
      "kind": "clinical",
      "materials": [
        "bite stick or tooth slooth",
        "transillumination light",
        "dye or methylene blue for crack staining",
        "periapical radiograph equipment",
        "provisional crown/band materials"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask about sharp pain specifically on release of biting pressure, sensitivity to cold, and whether pain lingers (suggesting pulpal involvement) or is momentary.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Take a focused history"
        },
        {
          "detail": "Use a bite stick or tooth-slooth device to test each cusp individually in isolation, looking to reproduce sharp pain specifically on release.\n\nWhy: Isolating the test to one cusp at a time localizes which cusp carries the crack; whole-tooth biting does not.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Perform a bite test on individual cusps",
          "why": "Isolating the test to one cusp at a time localizes which cusp carries the crack; whole-tooth biting does not."
        },
        {
          "detail": "Before proceeding to visual exam and treatment, the treating dentist explains that crack prognosis is uncertain and can only be confirmed over time, and documents the patient's informed consent to proceed with diagnostic testing and the likely management steps.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Discuss uncertainty of crack prognosis and obtain consent before management.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Discuss uncertainty of crack prognosis and obtain consent before management"
        },
        {
          "detail": "Transilluminate the tooth to look for a crack line, apply dye/methylene blue if helpful, remove any existing restoration if indicated to inspect the floor of the prep, and check for periodontal defects (a narrow deep pocket can indicate a vertical fracture).",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Visual and adjunct exam"
        },
        {
          "detail": "Perform cold and percussion testing to assess pulpal and periapical status, and take a periapical radiograph to check for a periapical radiolucency or a widened periodontal ligament space.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Test pulpal status and take a radiograph"
        },
        {
          "detail": "Determine severity and management path",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "craze-or-minor",
              "label": "Craze line or shallow crack, pulp vital and asymptomatic to cold, no periapical finding"
            },
            {
              "goto": "s10",
              "id": "cracked-tooth-symptomatic",
              "label": "Crack confirmed, pulp vital but symptomatic (reversible pulpitis pattern)"
            },
            {
              "goto": "s11",
              "id": "irreversible-pulpitis",
              "label": "Crack confirmed with irreversible pulpitis or periapical involvement"
            },
            {
              "goto": "s12",
              "id": "vertical-fracture",
              "label": "Vertical root fracture suspected (isolated deep narrow pocket, J-shaped lesion)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Determine severity and management path"
        },
        {
          "detail": "Consider bonding a shallow crack or placing an orthodontic band/provisional to limit cuspal flexure, and schedule a monitoring recall.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Manage conservatively and monitor"
        },
        {
          "detail": "Write a chart entry with the bite-test result, the transillumination and dye findings, the pulpal and periapical test results, and the management path chosen, with the patient discussion noted.\n\nRecord: Chart entry with bite-test result, transillumination/dye findings, pulpal and periapical test results, and the management path chosen with patient discussion noted.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document findings and chosen management"
        },
        {
          "detail": "Cracked tooth diagnosis and plan documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Cracked tooth diagnosis and plan documented"
        },
        {
          "detail": "Recommend a full-coverage restoration (onlay or crown) to splint the cracked cusps together and prevent propagation, and discuss timeline with the patient.\n\nWhy: Cuspal coverage reduces flexure across the crack, which is what drives the pain and crack propagation.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Place a cuspal-coverage protective restoration",
          "why": "Cuspal coverage reduces flexure across the crack, which is what drives the pain and crack propagation."
        },
        {
          "detail": "Diagnosis indicates irreversible pulpitis or periapical involvement from the crack; proceed under the practice's non-surgical root canal treatment protocol before restoring with cuspal coverage.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Route to root canal treatment protocol"
        },
        {
          "detail": "Explain that a vertical root fracture typically has a hopeless prognosis, and discuss extraction and replacement options.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss poor prognosis and extraction"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Cracked tooth diagnosis and management ladder — Sharp pain on release of biting with no obvious caries.",
      "title": "Cracked tooth diagnosis and management ladder",
      "trigger": "Sharp pain on release of biting with no obvious caries",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "IADT Guidelines for the Management of Traumatic Dental Injuries",
          "source": "IADT Guidelines for the Management of Traumatic Dental Injuries",
          "url": "https://www.iadt-dentaltrauma.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "endo-014",
      "kind": "clinical",
      "materials": [
        "storage medium (milk, saline, saliva, or dedicated tooth-preservation solution)",
        "flexible splinting material and wire/mesh",
        "local anesthetic",
        "periapical radiograph equipment",
        "tetanus status screening form",
        "systemic antibiotic formulary reference (tetracycline-class for patients approximately 12 years or older; pediatric-safe alternative below that age)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the call or arrival involves loss of consciousness, suspected head/neck/facial fracture, uncontrolled bleeding, or other signs of a medical emergency, instruct the caller to call 911 or direct them to the nearest emergency department before any dental guidance is given.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Screen for life-threatening injury before dental triage; call 911 if present.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Screen for life-threatening injury before dental triage; call 911 if present"
        },
        {
          "detail": "Is this an avulsed (knocked-out) tooth?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "avulsion",
              "label": "Tooth is completely out of the socket"
            },
            {
              "goto": "s4",
              "id": "luxation",
              "label": "Tooth is displaced but still in the socket, or chipped/loose"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this an avulsed (knocked-out) tooth?"
        },
        {
          "detail": "Instruct the caller to hold the tooth by the crown only (never the root), rinse debris briefly under water without scrubbing, reinsert it into the socket if possible and bite gently on gauze to hold it in place, or if reinsertion is not possible, place it in milk, saline, saliva, or a tooth-preservation solution — never dry or in tap water for storage. Tell them to come to the office immediately.\n\nWhy: IADT guidance identifies extraoral dry time as the strongest predictor of poor outcome; immediate reinsertion or wet storage preserves periodontal ligament cell viability.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Give phone instructions for handling the avulsed tooth",
          "why": "IADT guidance identifies extraoral dry time as the strongest predictor of poor outcome; immediate reinsertion or wet storage preserves periodontal ligament cell viability."
        },
        {
          "detail": "Bring the patient in as an immediate walk-in; do not place on a routine schedule.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "See the patient immediately"
        },
        {
          "detail": "Assess extraoral dry time and storage medium reported, examine for root fracture, alveolar fracture, and soft tissue injury, and take a radiograph to confirm tooth position and rule out root or bone fracture. Also screen whether the reported injury mechanism is consistent with the injury pattern observed (e.g., account inconsistent with findings, unexplained delay in presentation, other suspicious indicators); if inconsistent, follow the practice's mandated-reporting duty for suspected abuse or neglect.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Clinical and radiographic assessment on arrival"
        },
        {
          "detail": "Screen for known drug/anesthetic allergies, current medications, and anticoagulant use before administering local anesthetic for repositioning or replantation.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Screen medical history and allergies before local anesthetic"
        },
        {
          "detail": "For an avulsed tooth, is extraoral dry time within the favorable window or extended?\n\nWhy: IADT guidance treats extraoral dry time as the strongest predictor of periodontal ligament healing outcome; an extended dry time changes both the root-surface treatment and the prognosis discussion.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "favorable",
              "label": "Extraoral dry time approximately 60 minutes or less with viable wet storage, or the tooth was not avulsed (luxation only)"
            },
            {
              "goto": "s20",
              "id": "extended",
              "label": "Extraoral dry time greater than approximately 60 minutes, or the tooth was stored dry — periodontal ligament is non-viable"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "For an avulsed tooth, is extraoral dry time within the favorable window or extended?",
          "why": "IADT guidance treats extraoral dry time as the strongest predictor of periodontal ligament healing outcome; an extended dry time changes both the root-surface treatment and the prognosis discussion."
        },
        {
          "detail": "Route by injury type",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "avulsed-not-replanted",
              "label": "Tooth is avulsed and not yet reinserted"
            },
            {
              "goto": "s10",
              "id": "already-replanted",
              "label": "Tooth was already reinserted by the caller and is in the socket"
            },
            {
              "goto": "s21",
              "id": "luxated-displaced",
              "label": "Tooth is displaced/luxated but not avulsed"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Route by injury type"
        },
        {
          "detail": "Rinse the root surface gently with saline (do not scrub or curette the root surface), and reinsert the tooth into the socket with firm gentle pressure until it seats.\n\nWhy: Scrubbing the root removes remaining viable periodontal ligament cells, worsening long-term prognosis.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Gently rinse and replant the avulsed tooth",
          "why": "Scrubbing the root removes remaining viable periodontal ligament cells, worsening long-term prognosis."
        },
        {
          "detail": "Confirm the tooth is fully seated and in normal alignment with the arch, both visually and with a radiograph.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Verify tooth position radiographically and clinically"
        },
        {
          "detail": "Splint the tooth to adjacent stable teeth with a flexible splinting technique for the duration indicated by injury type (typically a short flexible splint for 2 weeks for most luxation/avulsion injuries per IADT guidance, longer for injuries with associated alveolar fracture).\n\nWhy: A flexible splint allows physiologic tooth movement during healing, which is associated with better periodontal ligament healing than a rigid splint.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Place a flexible splint",
          "why": "A flexible splint allows physiologic tooth movement during healing, which is associated with better periodontal ligament healing than a rigid splint."
        },
        {
          "detail": "Ask about tetanus vaccination status and the date of the injury; if immunization is not current, refer the patient to their physician or an urgent care clinic for a tetanus booster given the soil/oral contamination risk.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Screen tetanus status and refer if indicated"
        },
        {
          "detail": "Determine the systemic antibiotic course for the replanted/repositioned tooth by patient age",
          "forks": [
            {
              "advised": true,
              "goto": "s14",
              "id": "age-12-or-over",
              "label": "Patient is approximately 12 years or older — a tetracycline-class antibiotic course (e.g., doxycycline) is commonly used per IADT guidance"
            },
            {
              "goto": "s14",
              "id": "under-12",
              "label": "Patient is under approximately 12 years — avoid tetracycline-class antibiotics due to tooth staining; use a pediatric-appropriate alternative (e.g., penicillin/amoxicillin) per IADT guidance"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "dentist",
          "title": "Determine the systemic antibiotic course for the replanted/repositioned tooth by patient age"
        },
        {
          "detail": "Prescribe the age-appropriate systemic antibiotic course per office formulary and document the regimen, dose, and duration in the chart.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe the selected systemic antibiotic course"
        },
        {
          "detail": "Instruct on a soft diet, careful oral hygiene with a soft brush and chlorhexidine rinse around the splint, and warning signs (increasing pain, swelling, or tooth darkening) to call about immediately.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Give post-trauma instructions"
        },
        {
          "detail": "Explain to the patient or caregiver that the tooth's long-term prognosis depends heavily on extraoral dry time and injury type, that root canal treatment is frequently needed afterward (often starting within 7-10 days for a mature avulsed tooth), and document consent to the splinting and monitoring plan.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Discuss prognosis and obtain informed consent for the plan, including likely future root canal treatment.",
            "type": "safety"
          },
          "id": "s16",
          "kind": "gate",
          "role": "dentist",
          "title": "Discuss prognosis and obtain informed consent for the plan, including likely future root canal treatment"
        },
        {
          "detail": "Write a chart entry with the time of injury, the extraoral dry time and storage medium reported, the exam and radiographic findings, the treatment performed, the splint type and duration, the tetanus screening outcome, and the follow-up schedule.\n\nRecord: Chart entry with time of injury, extraoral dry time and storage medium, exam and radiographic findings, treatment performed, splint type and duration, tetanus screening outcome, and follow-up schedule.",
          "id": "s17",
          "kind": "step",
          "role": "dentist",
          "title": "Document the trauma encounter"
        },
        {
          "detail": "Schedule follow-up visits per IADT-recommended monitoring intervals (commonly 2 weeks, 4 weeks, 3 months, 6 months, and 1 year) and the splint-removal visit.",
          "id": "s18",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the follow-up and splint-removal visits"
        },
        {
          "detail": "Trauma managed, splinted and follow-up scheduled",
          "id": "s19",
          "kind": "step",
          "role": "dentist",
          "title": "Trauma managed, splinted and follow-up scheduled"
        },
        {
          "detail": "Gently debride the non-viable periodontal ligament remnants from the root surface before replantation, discuss with the patient or caregiver that ankylosis and replacement resorption are expected given the extended dry time, and set expectations for a guarded long-term prognosis; then proceed with replantation and splinting.",
          "id": "s20",
          "kind": "step",
          "role": "dentist",
          "title": "Manage the tooth as having a non-viable periodontal ligament"
        },
        {
          "detail": "Administer local anesthesia as needed and manually reposition the displaced tooth into normal alignment, confirming with a radiograph.",
          "id": "s21",
          "kind": "step",
          "role": "dentist",
          "title": "Reposition the luxated tooth under local anesthesia"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Dental trauma — luxation, avulsion replantation and splinting (permanent teeth) — A patient arrives or calls with a knocked-out or displaced permanent tooth — replant within the IADT window, splint, tetanus check.",
      "title": "Dental trauma — luxation, avulsion replantation and splinting (permanent teeth)",
      "trigger": "A patient arrives or calls with a knocked-out or displaced permanent tooth — replant within the IADT window, splint, tetanus check",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "IADT Guidelines for the Management of Traumatic Dental Injuries",
          "source": "IADT Guidelines for the Management of Traumatic Dental Injuries",
          "url": "https://www.iadt-dentaltrauma.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "endo-015",
      "kind": "clinical",
      "materials": [
        "calcium hydroxide or mineral trioxide aggregate for pulp capping",
        "bonding and composite materials for fragment reattachment or restoration",
        "periapical radiograph equipment",
        "cold test refrigerant"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Examine the extent of the fracture (enamel only, enamel-dentin, or with pulp exposure), test pulp vitality with cold, and take a radiograph to rule out a root fracture and check for a displaced fragment or foreign body in the lip/soft tissue.\n\nWhy: A radiograph of the lip and surrounding soft tissue rules out an embedded tooth fragment, a commonly missed finding in crown-fracture trauma.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Examine the fracture and test the tooth",
          "why": "A radiograph of the lip and surrounding soft tissue rules out an embedded tooth fragment, a commonly missed finding in crown-fracture trauma."
        },
        {
          "detail": "The treating dentist explains the fracture classification and pulp status to the patient or caregiver, discusses the likely management path, and documents informed consent before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Discuss findings and obtain consent before proceeding with management.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Discuss findings and obtain consent before proceeding with management"
        },
        {
          "detail": "Is the pulp exposed?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-exposure",
              "label": "No pulp exposure (enamel or enamel-dentin fracture)"
            },
            {
              "goto": "s8",
              "id": "pulp-exposed",
              "label": "Pulp is exposed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the pulp exposed?"
        },
        {
          "detail": "Smooth any sharp enamel edges, and either bond the original fragment back if available and viable, or restore with composite matched to the fracture line.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Smooth sharp edges and restore or reattach the fragment"
        },
        {
          "detail": "Write a chart entry with the fracture classification, the pulp status, the radiographic findings, the management performed, and the recall schedule.\n\nRecord: Chart entry with fracture classification, pulp status, radiographic findings, management performed, and recall schedule.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the fracture and management"
        },
        {
          "detail": "Schedule recall visits at approximately 6-8 weeks and 1 year to monitor pulp vitality and periapical status.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Schedule follow-up recalls"
        },
        {
          "detail": "Crown fracture managed and recall scheduled",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Crown fracture managed and recall scheduled"
        },
        {
          "detail": "Assess exposure size and time since injury",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "small-recent",
              "label": "Small pinpoint exposure, seen soon after injury, healthy pulp signs"
            },
            {
              "goto": "s10",
              "id": "large-or-delayed",
              "label": "Large exposure, delayed presentation, or signs of pulpal necrosis"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess exposure size and time since injury"
        },
        {
          "detail": "Manage the exposure with a direct pulp cap or partial pulpotomy per the practice's vital pulp therapy protocol, then restore the crown.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Route to vital pulp therapy protocol"
        },
        {
          "detail": "Discuss with the patient that root canal treatment is indicated given the exposure size, delay, or pulpal status, and either proceed under the practice's root canal treatment protocol or refer per case difficulty.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Plan for root canal treatment or refer"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Crown fracture — uncomplicated and complicated (pulp exposed) management — Trauma fractures a tooth crown.",
      "title": "Crown fracture — uncomplicated and complicated (pulp exposed) management",
      "trigger": "Trauma fractures a tooth crown",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "repaired": {
            "action": "reduce",
            "evidence": "AAE's Case Assessment Tools page: 'The AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula as well as by dentists to help with case decision making and recordkeeping... The form has three parts: general health consideration, diagnosis and treatment condition, and additional contributing factors such as trauma, previous treatment, and periodontal disease... with final assignment to three difficulty levels: minimal, moderate, and high.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AAE endodontic diagnosis, case difficulty assessment and treatment standards",
              "url": "https://www.aae.org/specialty/clinical-resources/"
            }
          },
          "source": "AAE Case Assessment Tools — endodontic diagnosis and case-difficulty assessment (confirmed page, narrower than general 'treatment standards')",
          "url": "https://www.aae.org/specialty/clinical-resources/treatment-planning/case-assessment-tools/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.4 (in-repo root canal basis)"
        }
      ],
      "class": "endodontics",
      "department": "clinical",
      "duration_min": 50,
      "frequency": "as-needed",
      "id": "endo-016",
      "kind": "clinical",
      "materials": [
        "rubber dam for isolation",
        "high-speed handpiece with sterile bur for pulpotomy",
        "sodium hypochlorite or saline for hemostasis irrigation",
        "calcium hydroxide, mineral trioxide aggregate, or bioceramic pulp-capping material",
        "cold test refrigerant",
        "periapical radiograph equipment"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the tooth has a carious or mechanical pulp exposure, a positive and normal response to cold testing beforehand, no spontaneous or lingering pain history suggesting irreversible pulpitis, and no periapical radiolucency on the radiograph.\n\nWhy: Vital pulp therapy depends on the remaining pulp being healthy enough to heal; signs of irreversible pulpitis change the indicated treatment to root canal therapy.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the tooth is a candidate for vital pulp therapy",
          "why": "Vital pulp therapy depends on the remaining pulp being healthy enough to heal; signs of irreversible pulpitis change the indicated treatment to root canal therapy."
        },
        {
          "detail": "Explain that vital pulp therapy aims to preserve the living pulp with a success rate that depends on exposure size and pulpal health, that root canal treatment remains a fallback if it fails, and document the patient's informed consent to proceed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Discuss vital pulp therapy versus root canal treatment and obtain consent.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Discuss vital pulp therapy versus root canal treatment and obtain consent"
        },
        {
          "detail": "Before anesthetic is given, screen for known drug/anesthetic allergies and current medications, including anticoagulant use; also confirm no known latex allergy before rubber dam isolation.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Screen medical history and allergies before anesthesia and rubber dam isolation"
        },
        {
          "detail": "Administer local anesthesia and place a rubber dam for isolation before removing caries.\n\nWhy: A contaminated field is a leading cause of vital pulp therapy failure; rubber dam isolation keeps saliva and bacteria out of the exposure site.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Anesthetize and isolate with a rubber dam",
          "why": "A contaminated field is a leading cause of vital pulp therapy failure; rubber dam isolation keeps saliva and bacteria out of the exposure site."
        },
        {
          "detail": "Remove all caries with a sterile bur under copious irrigation, exposing the pulp.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Remove caries and expose sound pulp tissue"
        },
        {
          "detail": "Irrigate the exposed pulp with sodium hypochlorite or saline and observe bleeding color and time to hemostasis.\n\nWhy: Bleeding that stops promptly and looks bright red suggests healthy underlying pulp suitable for capping; prolonged or dark bleeding suggests deeper inflammation.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Assess pulpal bleeding after exposure",
          "why": "Bleeding that stops promptly and looks bright red suggests healthy underlying pulp suitable for capping; prolonged or dark bleeding suggests deeper inflammation."
        },
        {
          "detail": "Does the pulp achieve hemostasis within the target window?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "hemostasis-achieved",
              "label": "Bleeding controlled promptly, tissue appears healthy"
            },
            {
              "goto": "s14",
              "id": "no-hemostasis",
              "label": "Bleeding does not stop within the target window, or tissue appears necrotic"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the pulp achieve hemostasis within the target window?"
        },
        {
          "detail": "Partial pulpotomy or full coronal pulpotomy?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "partial",
              "label": "Small exposure — remove 1-2mm of pulp tissue (partial pulpotomy)"
            },
            {
              "goto": "s9",
              "id": "full",
              "label": "Larger exposure — remove pulp tissue to the level of the canal orifices (full coronal pulpotomy)"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Partial pulpotomy or full coronal pulpotomy?"
        },
        {
          "detail": "Place calcium hydroxide, mineral trioxide aggregate, or a bioceramic material directly over the remaining pulp tissue per manufacturer instructions.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Place the pulp-capping material"
        },
        {
          "detail": "Restore the tooth with a bonded restoration that provides a complete coronal seal over the capping material.\n\nWhy: A coronal microleak defeats vital pulp therapy regardless of how well the capping material was placed.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Place a well-sealed restoration",
          "why": "A coronal microleak defeats vital pulp therapy regardless of how well the capping material was placed."
        },
        {
          "detail": "Write a chart entry with the exposure size, the hemostasis findings, the capping extent (partial or full), the material used, the restoration placed, and the recall schedule.\n\nRecord: Chart entry with exposure size, hemostasis findings, capping extent (partial or full), material used, restoration placed, and recall schedule.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Schedule recall visits (commonly 6 months and 1 year) with cold testing and a periapical radiograph to confirm continued vitality and absence of periapical pathology.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Schedule recall to monitor pulp vitality"
        },
        {
          "detail": "Vital pulp therapy documented and recall scheduled",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Vital pulp therapy documented and recall scheduled"
        },
        {
          "detail": "Inform the patient that the pulp did not show signs consistent with a favorable prognosis for capping, and proceed under the practice's non-surgical root canal treatment protocol in the same or a subsequent visit.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Convert to non-surgical root canal treatment"
        }
      ],
      "subclass": "endodontic-diagnosis-and-treatment",
      "summary": "Vital pulp therapy (partial or full pulpotomy) in mature permanent teeth — A carious exposure in a vital tooth where pulp preservation is chosen over root canal treatment.",
      "title": "Vital pulp therapy (partial or full pulpotomy) in mature permanent teeth",
      "trigger": "A carious exposure in a vital tooth where pulp preservation is chosen over root canal treatment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "source": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "url": "https://www.ecfr.gov/current/title-40/part-441"
        },
        {
          "kind": "statute",
          "label": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "source": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalWaste.aspx"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 90,
      "frequency": "once",
      "id": "env-001",
      "kind": "compliance",
      "materials": [
        "ISO 11143-certified amalgam separator unit",
        "manufacturer installation instructions",
        "EPA/local control authority one-time compliance report form",
        "plumbing or facilities contractor",
        "practice compliance file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the practice places or removes amalgam restorations; practices limited to specialties such as oral surgery, orthodontics, periodontics, prosthodontics, radiology or pediatric dentistry with no amalgam use may qualify for a one-time exemption filing instead of installation.\n\nWhy: 40 CFR Part 441 exempts a small set of dental specialties that never place or remove amalgam — confirming applicability first avoids installing equipment the rule does not require.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Determine whether the EPA dental amalgam rule applies to this practice",
          "why": "40 CFR Part 441 exempts a small set of dental specialties that never place or remove amalgam — confirming applicability first avoids installing equipment the rule does not require."
        },
        {
          "detail": "Does the practice qualify for the amalgam-exempt specialty exclusion?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "not-exempt",
              "label": "Practice places or removes amalgam"
            },
            {
              "goto": "s9",
              "id": "exempt",
              "label": "Practice is a qualifying no-amalgam specialty"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the practice qualify for the amalgam-exempt specialty exclusion?"
        },
        {
          "detail": "Choose a separator rated at least 95% removal efficiency per ISO 11143 sized to the number of chairs and vacuum system in use.\n\nWhy: The EPA rule requires ISO 11143 certification, not just any trap or filter — an uncertified unit does not satisfy the compliance report.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Select and order an ISO 11143-certified amalgam separator",
          "why": "The EPA rule requires ISO 11143 certification, not just any trap or filter — an uncertified unit does not satisfy the compliance report."
        },
        {
          "detail": "A plumbing or facilities contractor installs the unit inline with the vacuum system per the manufacturer's instructions and local plumbing code.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "ISO 11143-certified amalgam separator unit",
            "manufacturer installation instructions"
          ],
          "role": "it-vendor",
          "title": "Install the separator per manufacturer instructions"
        },
        {
          "detail": "Train assistants and sterilization staff on the monthly inspection protocol (env-002), amalgam waste handling (env-003) and the vacuum line cleaner restriction (env-004) before first use.\n\nWhy: The one-time compliance report certifies not just the hardware but that best management practices are followed going forward.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Train clinical staff on inspection, waste handling and best management practices",
          "why": "The one-time compliance report certifies not just the hardware but that best management practices are followed going forward."
        },
        {
          "detail": "Practice owner reviews the completed compliance report (separator make/model, install date, certification) and signs before it is submitted.\n\nWhy: The compliance report is a regulatory attestation; the practice owner is the accountable signatory to the control authority.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner reviews and signs the one-time compliance report before filing.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner reviews and signs the one-time compliance report before filing",
          "why": "The compliance report is a regulatory attestation; the practice owner is the accountable signatory to the control authority."
        },
        {
          "detail": "Submit the signed one-time compliance report to the local control authority and file the copy.\n\nWhy: 40 CFR 441.50 requires the report be kept and available for inspection; there is no expiration on retention.\n\nRecord: One-time compliance report submitted to the local control authority (sewer authority or as directed); copy with install date, model, and ISO 11143 certificate retained in the compliance file indefinitely.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the compliance report and retain the record",
          "why": "40 CFR 441.50 requires the report be kept and available for inspection; there is no expiration on retention."
        },
        {
          "detail": "Amalgam separator compliance established",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Amalgam separator compliance established"
        },
        {
          "detail": "File the signed one-time exemption compliance report with the local control authority.\n\nWhy: The rule still requires a one-time filing from exempt practices; only the separator installation requirement is waived.\n\nRecord: Signed one-time compliance report checking the exemption box, filed to the local control authority and retained in the compliance file indefinitely.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "File the one-time exemption compliance report",
          "why": "The rule still requires a one-time filing from exempt practices; only the separator installation requirement is waived."
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Amalgam separator installation and one-time compliance report to the control authority — A practice that places or removes amalgam opens, changes ownership, or replaces its separator.",
      "title": "Amalgam separator installation and one-time compliance report to the control authority",
      "trigger": "A practice that places or removes amalgam opens, changes ownership, or replaces its separator",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "source": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "url": "https://www.ecfr.gov/current/title-40/part-441"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 15,
      "frequency": "monthly",
      "id": "env-002",
      "kind": "compliance",
      "materials": [
        "manufacturer inspection checklist",
        "replacement cartridge (manufacturer-specified)",
        "personal protective equipment (gloves, eye protection)",
        "inspection log (paper or digital)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the separator's fill indicator, look for visible leakage, cracking, or bypass around the unit, and confirm the vacuum system is drawing normally.\n\nWhy: A monthly check is the manufacturer-typical minimum for catching a failing unit before it discharges amalgam to the sewer.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "manufacturer inspection checklist",
            "personal protective equipment (gloves, eye protection)"
          ],
          "role": "sterilization-tech",
          "title": "Perform the scheduled monthly visual inspection",
          "why": "A monthly check is the manufacturer-typical minimum for catching a failing unit before it discharges amalgam to the sewer."
        },
        {
          "detail": "What does the inspection show?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "normal",
              "label": "No fill indicator, no leakage or bypass"
            },
            {
              "goto": "s5",
              "id": "full",
              "label": "Fill indicator triggered or cartridge visibly full"
            },
            {
              "goto": "s7",
              "id": "leak",
              "label": "Leakage, cracking or bypass observed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "What does the inspection show?"
        },
        {
          "detail": "Record the inspection date, inspector initials, and 'no findings' in the log.\n\nRecord: Inspection date, inspector initials, and 'no findings' entered in the inspection log.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the routine inspection as normal"
        },
        {
          "detail": "Monthly inspection cycle complete",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Monthly inspection cycle complete"
        },
        {
          "detail": "Replace the cartridge or collection container following the manufacturer's change-out procedure; treat the removed cartridge as amalgam waste (env-003).\n\nWhy: A full separator no longer removes amalgam from the wastewater stream, defeating the point of the rule.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "replacement cartridge (manufacturer-specified)"
          ],
          "role": "sterilization-tech",
          "title": "Change the separator cartridge per manufacturer instructions",
          "why": "A full separator no longer removes amalgam from the wastewater stream, defeating the point of the rule."
        },
        {
          "detail": "Record the cartridge change date, lot/serial, and inspector initials in the log.\n\nRecord: Change-out date, cartridge lot/serial if provided, inspector initials, and handoff note to amalgam waste handling entered in the inspection log.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the cartridge change"
        },
        {
          "detail": "Stop amalgam procedures on the affected line or chair, contact the separator manufacturer or a qualified plumbing contractor for repair, and do not resume use until the unit is confirmed intact.\n\nWhy: A leaking or bypassing separator can discharge amalgam directly to the sanitary sewer, which is the exact outcome the rule exists to prevent.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Take the affected vacuum line out of service until repaired",
          "why": "A leaking or bypassing separator can discharge amalgam directly to the sanitary sewer, which is the exact outcome the rule exists to prevent."
        },
        {
          "detail": "Record the leak date, description, repair contractor, and return-to-service date.\n\nRecord: Date found, description of the leak or bypass, line taken out of service, repair contractor, and date confirmed returned to service, entered in the inspection log and retained in the compliance file.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the failure, repair action, and return-to-service date"
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Amalgam separator monthly inspection, cartridge change, bypass check and record retention — The monthly inspection date, or the separator's full indicator triggers or a visual inspection finds bypass or leakage.",
      "title": "Amalgam separator monthly inspection, cartridge change, bypass check and record retention",
      "trigger": "The monthly inspection date, or the separator's full indicator triggers or a visual inspection finds bypass or leakage",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "source": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "url": "https://www.ecfr.gov/current/title-40/part-441"
        },
        {
          "kind": "statute",
          "label": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "source": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalWaste.aspx"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "env-003",
      "kind": "compliance",
      "materials": [
        "labeled amalgam waste container (non-oxidizing, no bleach contact)",
        "chairside trap and vacuum filter screens",
        "personal protective equipment (gloves)",
        "amalgam recycler pickup or mail-back kit"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Place contact amalgam scrap (from restoration placement or removal), chairside traps, and vacuum filter screens directly into the labeled amalgam waste container as they are generated; never rinse amalgam waste down a sink or into the vacuum system.\n\nWhy: Amalgam contains mercury; rinsing it down a drain defeats the separator and best management practices this class exists to enforce.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "labeled amalgam waste container (non-oxidizing, no bleach contact)"
          ],
          "role": "assistant",
          "title": "Collect amalgam scrap into the labeled non-oxidizing waste container",
          "why": "Amalgam contains mercury; rinsing it down a drain defeats the separator and best management practices this class exists to enforce."
        },
        {
          "detail": "Never use bleach, chlorine-based disinfectant, or strong acid to clean instruments or surfaces over or near the open amalgam waste container.\n\nWhy: Oxidizers convert metallic mercury in amalgam scrap into soluble, more hazardous mercury compounds — this is a named EPA best management practice.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Keep bleach and other oxidizing or acidic disinfectants away from the amalgam container",
          "why": "Oxidizers convert metallic mercury in amalgam scrap into soluble, more hazardous mercury compounds — this is a named EPA best management practice."
        },
        {
          "detail": "Is an extracted tooth with an amalgam restoration being disposed of (not returned to the patient)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-amalgam-tooth",
              "label": "No extracted amalgam-bearing tooth this cycle"
            },
            {
              "goto": "s6",
              "id": "amalgam-tooth",
              "label": "Extracted tooth has amalgam and is not being returned to the patient"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is an extracted tooth with an amalgam restoration being disposed of (not returned to the patient)?"
        },
        {
          "detail": "Is the amalgam waste container full or nearing capacity?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "not-full",
              "label": "Container has capacity remaining"
            },
            {
              "goto": "s7",
              "id": "full",
              "label": "Container is full or the label capacity is reached"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Is the amalgam waste container full or nearing capacity?"
        },
        {
          "detail": "Amalgam waste handled and stored or shipped for recycling",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Amalgam waste handled and stored or shipped for recycling"
        },
        {
          "detail": "Extracted teeth with amalgam restorations that are not returned to the patient (env-013) go into the amalgam waste container, not the regulated medical waste (sharps/biohazard) stream.\n\nWhy: Amalgam-bearing teeth are managed as amalgam waste under the recycler stream, separate from the biohazard waste stream.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Place the amalgam-bearing extracted tooth into the amalgam waste container",
          "why": "Amalgam-bearing teeth are managed as amalgam waste under the recycler stream, separate from the biohazard waste stream."
        },
        {
          "detail": "Seal the full container per the recycler's instructions and schedule pickup or send via the recycler's mail-back kit.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "amalgam recycler pickup or mail-back kit"
          ],
          "role": "sterilization-tech",
          "title": "Seal the container and schedule recycler pickup or mail-back"
        },
        {
          "detail": "Record the pickup/ship date, recycler name, and container count; keep the receipt.\n\nWhy: A retained receipt is the evidence trail showing amalgam waste left the practice through the recycling stream, not the trash or the drain.\n\nRecord: Pickup or ship date, recycler name, and container count logged; recycler receipt or certificate of recycling retained in the compliance file.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the pickup and retain the recycler receipt",
          "why": "A retained receipt is the evidence trail showing amalgam waste left the practice through the recycling stream, not the trash or the drain."
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Amalgam waste (contact and non-contact scrap, traps, extracted teeth with amalgam) handling and recycler pickup — Chairside traps or vacuum filters are changed, or the amalgam container is full.",
      "title": "Amalgam waste (contact and non-contact scrap, traps, extracted teeth with amalgam) handling and recycler pickup",
      "trigger": "Chairside traps or vacuum filters are changed, or the amalgam container is full",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "source": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices, one-time compliance report)",
          "url": "https://www.ecfr.gov/current/title-40/part-441"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "env-004",
      "kind": "compliance",
      "materials": [
        "product safety data sheet (SDS)",
        "vacuum line cleaner product",
        "staff instruction sheet or posted reminder"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Review the product's SDS for pH and oxidizer content before it is ordered or brought into use on the vacuum system.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "product safety data sheet (SDS)"
          ],
          "role": "compliance-officer",
          "title": "Check the safety data sheet before approving any vacuum line cleaner"
        },
        {
          "detail": "Is the product pH 6–8 and non-oxidizing (no bleach/chlorine, no strong acid)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "compliant",
              "label": "pH 6–8, non-oxidizing"
            },
            {
              "goto": "s6",
              "id": "non-compliant",
              "label": "Bleach-based, strongly acidic, or oxidizing"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the product pH 6–8 and non-oxidizing (no bleach/chlorine, no strong acid)?"
        },
        {
          "detail": "Add the product to the practice's approved vacuum line cleaner list and place the order.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Add the product to the approved list and order it"
        },
        {
          "detail": "Post or distribute the current approved product name and remind staff at the next huddle that bleach-based cleaners must never go into the vacuum system.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "staff instruction sheet or posted reminder"
          ],
          "role": "sterilization-tech",
          "title": "Instruct clinical staff to use only the approved line cleaner"
        },
        {
          "detail": "Line cleaner reviewed and staff instructed",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Line cleaner reviewed and staff instructed"
        },
        {
          "detail": "Do not order the product; if a bleach-based or oxidizing cleaner is already in use, pull it from the operatories immediately and substitute an approved product.\n\nWhy: Bleach and other oxidizers dissolve metallic mercury in amalgam waste into soluble compounds that pass through the separator — this is the EPA's named best management practice violation.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Reject the product and remove any existing stock from use",
          "why": "Bleach and other oxidizers dissolve metallic mercury in amalgam waste into soluble compounds that pass through the separator — this is the EPA's named best management practice violation."
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Vacuum line cleaner selection (pH 6–8, non-oxidizing) and staff instruction — A new line cleaner product is ordered, or a bleach-based product is found in use.",
      "title": "Vacuum line cleaner selection (pH 6–8, non-oxidizing) and staff instruction",
      "trigger": "A new line cleaner product is ordered, or a bleach-based product is found in use",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "source": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalWaste.aspx"
        },
        {
          "kind": "regulation",
          "label": "RCRA hazardous waste generator standards 40 CFR Part 262; hazardous waste pharmaceuticals 40 CFR 266 Subpart P",
          "source": "RCRA hazardous waste generator standards 40 CFR Part 262; hazardous waste pharmaceuticals 40 CFR 266 Subpart P",
          "url": "https://www.ecfr.gov/current/title-40/part-262"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 45,
      "frequency": "annual",
      "id": "env-005",
      "kind": "compliance",
      "materials": [
        "county or state medical waste generator registration form",
        "prior year's registration/permit for renewal reference",
        "renewal fee payment method",
        "compliance calendar"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify whether the practice is a small or large quantity generator under the applicable state medical waste act and which agency (county environmental health department or state) accepts the registration.\n\nWhy: Filing authority and category vary by state and by waste volume; filing with the wrong agency delays registration.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Determine the practice's medical waste generator category and filing authority",
          "why": "Filing authority and category vary by state and by waste volume; filing with the wrong agency delays registration."
        },
        {
          "detail": "Is this a new registration or an annual renewal?",
          "forks": [
            {
              "goto": "s9",
              "id": "new",
              "label": "New practice, new address, or first-time registration"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "renewal",
              "label": "Annual renewal of an existing registration"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a new registration or an annual renewal?"
        },
        {
          "detail": "Update the prior year's registration with any changes (hauler, address, generator category) and submit before the expiration date with the renewal fee.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "prior year's registration/permit for renewal reference",
            "renewal fee payment method"
          ],
          "role": "office-manager",
          "title": "Complete and submit the annual renewal application"
        },
        {
          "detail": "Practice owner confirms the application details are accurate and authorizes the filing fee before it is submitted to the agency.\n\nWhy: The registration is a legal representation to a regulatory agency and a recurring fee obligation — the owner is the accountable party.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner reviews the registration before submission.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner reviews the registration before submission",
          "why": "The registration is a legal representation to a regulatory agency and a recurring fee obligation — the owner is the accountable party."
        },
        {
          "detail": "Submit the registration or renewal to the county or state agency and retain the confirmation or receipt.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the application and retain proof of filing"
        },
        {
          "detail": "Enter the registration's expiration date and a lead-time reminder (e.g. 60 days prior) on the practice compliance calendar.\n\nWhy: Missing an annual renewal deadline lapses the practice's legal authority to generate and transfer regulated medical waste.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "compliance calendar"
          ],
          "role": "compliance-officer",
          "title": "Set the next-year renewal reminder on the compliance calendar",
          "why": "Missing an annual renewal deadline lapses the practice's legal authority to generate and transfer regulated medical waste."
        },
        {
          "detail": "File the registration number, agency, filing date, and expiration date.\n\nRecord: Registration/permit number, issuing agency, filing date, expiration date, and confirmation receipt retained in the compliance file.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the registration and confirmation in the compliance file"
        },
        {
          "detail": "Medical waste generator registration current",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Medical waste generator registration current"
        },
        {
          "detail": "Complete the county or state medical waste generator registration form with practice name, address, generator category, and waste hauler information; submit with the required fee.",
          "id": "s9",
          "kind": "step",
          "materials": [
            "county or state medical waste generator registration form"
          ],
          "role": "office-manager",
          "title": "Complete and submit the new generator registration application"
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Regulated medical waste generator registration or permit and annual renewal (CA addendum) — The practice opens, changes address, or the annual county or state renewal is due.",
      "title": "Regulated medical waste generator registration or permit and annual renewal (CA addendum)",
      "trigger": "The practice opens, changes address, or the annual county or state renewal is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(d)(4)(iii) regulated waste containment; Hazard Communication 1910.1200; EPA mercury spill cleanup guidance",
          "source": "OSHA 29 CFR 1910.1030(d)(4)(iii) regulated waste containment; Hazard Communication 1910.1200; EPA mercury spill cleanup guidance",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "statute",
          "label": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "source": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalWaste.aspx"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 20,
      "frequency": "monthly",
      "id": "env-006",
      "kind": "compliance",
      "materials": [
        "red biohazard bags and rigid sharps containers",
        "regulated waste manifest or trip ticket (hauler-supplied)",
        "designated storage area",
        "compliance file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "assistant",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check sharps containers and red bag storage during routine operatory turnover; a sharps container is full at the manufacturer's fill line, never packed down or overfilled.\n\nWhy: A sharps container filled past the line is the leading cause of handling injuries during pickup — see the overfill protocol (env-008).",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Monitor sharps containers and biohazard bags for fill level",
          "why": "A sharps container filled past the line is the leading cause of handling injuries during pickup — see the overfill protocol (env-008)."
        },
        {
          "detail": "Is this the scheduled pickup date, or did a container reach the fill line early?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "scheduled",
              "label": "Scheduled pickup date has arrived"
            },
            {
              "goto": "s8",
              "id": "early-full",
              "label": "Container full before the scheduled date"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Is this the scheduled pickup date, or did a container reach the fill line early?"
        },
        {
          "detail": "Seal full sharps containers and red bags and move them to the practice's designated regulated waste storage area to await the hauler.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "red biohazard bags and rigid sharps containers",
            "designated storage area"
          ],
          "role": "sterilization-tech",
          "title": "Stage sealed containers in the designated storage area for pickup"
        },
        {
          "detail": "Confirm the hauler's identification, hand off the staged containers, and receive the manifest or trip ticket for the load.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Meet the hauler and hand off the containers"
        },
        {
          "detail": "Verify the manifest lists the correct generator name, address, waste category and container counts, then sign before the hauler leaves the premises.\n\nWhy: The manifest is the practice's chain-of-custody record for regulated medical waste; signing it later or not at all leaves no proof of proper transfer.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Review and sign the regulated waste manifest before the hauler departs.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Review and sign the regulated waste manifest before the hauler departs",
          "why": "The manifest is the practice's chain-of-custody record for regulated medical waste; signing it later or not at all leaves no proof of proper transfer."
        },
        {
          "detail": "File the signed manifest with pickup date, hauler name, and container counts.\n\nRecord: Signed manifest or trip ticket with pickup date, hauler name, and container counts retained in the compliance file for the state-required retention period.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "regulated waste manifest or trip ticket (hauler-supplied)",
            "compliance file"
          ],
          "role": "compliance-officer",
          "title": "Retain the signed manifest in the compliance file"
        },
        {
          "detail": "Regulated waste picked up and manifested",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Regulated waste picked up and manifested"
        },
        {
          "detail": "Contact the regulated waste hauler to schedule pickup ahead of the routine cadence rather than storing a full container past the allowed accumulation time.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Call the hauler to request an early pickup"
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Regulated medical waste and sharps pickup scheduling, manifest signature and retention — The scheduled hauler pickup, or a container reaches the fill line.",
      "title": "Regulated medical waste and sharps pickup scheduling, manifest signature and retention",
      "trigger": "The scheduled hauler pickup, or a container reaches the fill line",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "source": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalWaste.aspx"
        },
        {
          "kind": "regulation",
          "label": "RCRA hazardous waste generator standards 40 CFR Part 262; hazardous waste pharmaceuticals 40 CFR 266 Subpart P",
          "source": "RCRA hazardous waste generator standards 40 CFR Part 262; hazardous waste pharmaceuticals 40 CFR 266 Subpart P",
          "url": "https://www.ecfr.gov/current/title-40/part-262"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "env-007",
      "kind": "compliance",
      "materials": [
        "hauler contract and contact information",
        "designated storage area",
        "backup hauler contact list",
        "compliance calendar"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the pickup schedule and confirm the hauler has not arrived or collected the waste by the end of the scheduled pickup window.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the pickup was missed"
        },
        {
          "detail": "Call the regulated waste hauler using the contract contact information to determine the cause of the missed pickup and get a new pickup date.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "hauler contract and contact information"
          ],
          "role": "office-manager",
          "title": "Contact the hauler to reschedule"
        },
        {
          "detail": "Will storage exceed the state's allowed accumulation time or volume before the new pickup date?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "within-limit",
              "label": "New pickup date is within the allowed accumulation time/volume"
            },
            {
              "goto": "s8",
              "id": "exceeds-limit",
              "label": "New pickup date exceeds the allowed accumulation time or volume"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Will storage exceed the state's allowed accumulation time or volume before the new pickup date?"
        },
        {
          "detail": "Ensure all regulated waste remains sealed and in the designated storage area, inaccessible to patients and the public, until the rescheduled or backup pickup occurs.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "designated storage area"
          ],
          "role": "sterilization-tech",
          "title": "Keep waste in the designated, secured storage area until pickup"
        },
        {
          "detail": "Record the missed pickup date, hauler response, backup hauler use, and resolution date.\n\nWhy: A logged near-miss shows the practice actively managed the exception rather than silently exceeding the accumulation limit, and informs whether the hauler contract needs review.\n\nRecord: Missed pickup date, hauler response, whether a backup hauler was used, resolution date, and total storage duration logged in the compliance file.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the missed pickup, cause, and resolution",
          "why": "A logged near-miss shows the practice actively managed the exception rather than silently exceeding the accumulation limit, and informs whether the hauler contract needs review."
        },
        {
          "detail": "If the same hauler has missed pickups more than once in a review period, raise the pattern with the vendor or evaluate switching haulers.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Review hauler reliability if pickups are missed repeatedly"
        },
        {
          "detail": "Missed pickup resolved and logged",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Missed pickup resolved and logged"
        },
        {
          "detail": "Contact a backup or alternate licensed regulated medical waste hauler to arrange pickup before the accumulation limit is exceeded.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "backup hauler contact list"
          ],
          "role": "office-manager",
          "title": "Call a backup hauler for emergency pickup"
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Medical waste hauler misses pickup or the accumulation limit approaches — Regulated waste has not been collected by the scheduled date, or storage exceeds allowed time or volume.",
      "title": "Medical waste hauler misses pickup or the accumulation limit approaches",
      "trigger": "Regulated waste has not been collected by the scheduled date, or storage exceeds allowed time or volume",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(d)(4)(iii) regulated waste containment; Hazard Communication 1910.1200; EPA mercury spill cleanup guidance",
          "source": "OSHA 29 CFR 1910.1030(d)(4)(iii) regulated waste containment; Hazard Communication 1910.1200; EPA mercury spill cleanup guidance",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "env-008",
      "kind": "compliance",
      "materials": [
        "heavy-duty puncture-resistant gloves",
        "spare rigid sharps container",
        "forceps or mechanical pickup tool",
        "exposure incident report form",
        "compliance file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Stop; do not reach into or press down the contents of an overfilled, cracked or tipped sharps container.\n\nWhy: OSHA 29 CFR 1910.1030(d)(4)(iii) requires sharps containers be closable, puncture-resistant, and not overfilled — a compromised container is the highest-risk state for a needlestick.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Do not handle the container or its contents with bare or single-gloved hands",
          "why": "OSHA 29 CFR 1910.1030(d)(4)(iii) requires sharps containers be closable, puncture-resistant, and not overfilled — a compromised container is the highest-risk state for a needlestick."
        },
        {
          "detail": "Did anyone contact exposed contents (skin, mucous membrane, or a puncture occurred)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-exposure",
              "label": "No one contacted the exposed contents"
            },
            {
              "goto": "s10",
              "id": "exposure",
              "label": "Someone was punctured or contacted exposed contents"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did anyone contact exposed contents (skin, mucous membrane, or a puncture occurred)?"
        },
        {
          "detail": "Put on heavy-duty puncture-resistant gloves (over exam gloves if needed) before touching the container or surrounding area.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "heavy-duty puncture-resistant gloves"
          ],
          "role": "sterilization-tech",
          "title": "Don heavy-duty puncture-resistant gloves before approaching the container"
        },
        {
          "detail": "Is the container overfilled but intact, or cracked/tipped with contents spilled out?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "overfilled-intact",
              "label": "Overfilled but the container body is intact and closable"
            },
            {
              "goto": "s12",
              "id": "breached",
              "label": "Container is cracked, punctured, or contents are spilled outside it"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Is the container overfilled but intact, or cracked/tipped with contents spilled out?"
        },
        {
          "detail": "Close the container's lid/seal as-is without pressing contents down, and replace it with a fresh container for ongoing use.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "spare rigid sharps container"
          ],
          "role": "sterilization-tech",
          "title": "Close and seal the overfilled container without repacking it"
        },
        {
          "detail": "Move the newly sealed container to the designated regulated waste storage area to await the next scheduled or early pickup (env-006/env-007).",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Move the sealed replacement container to designated storage"
        },
        {
          "detail": "Compliance officer confirms the incident report accurately reflects that no one was exposed, or that the exposure protocol was properly initiated, before the incident is closed out.\n\nWhy: A sharps container breach is a bloodborne pathogen exposure control program event under OSHA and needs a documented, reviewed closure regardless of outcome.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews the finding and confirms no exposure occurred.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews the finding and confirms no exposure occurred",
          "why": "A sharps container breach is a bloodborne pathogen exposure control program event under OSHA and needs a documented, reviewed closure regardless of outcome."
        },
        {
          "detail": "Record the finding date, container condition, recovery outcome, and exposure status.\n\nRecord: Date and location found, container condition, whether contents were recovered, whether any exposure occurred, and corrective action taken, entered in the exposure incident report form and retained in the compliance file.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "exposure incident report form",
            "compliance file"
          ],
          "role": "compliance-officer",
          "title": "Document the finding and corrective action"
        },
        {
          "detail": "Sharps container secured and incident documented",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Sharps container secured and incident documented"
        },
        {
          "detail": "Stop this cleanup and follow the practice's bloodborne pathogen post-exposure protocol immediately (wash/flush the site, report to the supervisor, seek medical evaluation) before returning to secure the container.\n\nWhy: A sharps exposure event takes priority over container cleanup and has its own time-sensitive medical follow-up window.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hand off to the bloodborne pathogen exposure protocol",
          "why": "A sharps exposure event takes priority over container cleanup and has its own time-sensitive medical follow-up window."
        },
        {
          "detail": "Exposure protocol engaged; sharps cleanup resumes after medical follow-up",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Exposure protocol engaged; sharps cleanup resumes after medical follow-up"
        },
        {
          "detail": "Using forceps or a mechanical pickup tool (never fingers), transfer loose sharps into a new rigid sharps container; dispose of the breached container itself as sharps waste as well.\n\nWhy: Mechanical pickup tools keep hands out of the path of an exposed needle or blade during recovery.",
          "id": "s12",
          "kind": "step",
          "materials": [
            "forceps or mechanical pickup tool",
            "spare rigid sharps container"
          ],
          "role": "sterilization-tech",
          "title": "Recover spilled sharps into a new container using mechanical means only",
          "why": "Mechanical pickup tools keep hands out of the path of an exposed needle or blade during recovery."
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Sharps container overfilled, punctured or spilled — A sharps container is found beyond the fill line, cracked, or tipped with contents exposed.",
      "title": "Sharps container overfilled, punctured or spilled",
      "trigger": "A sharps container is found beyond the fill line, cracked, or tipped with contents exposed",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "RCRA hazardous waste generator standards 40 CFR Part 262; hazardous waste pharmaceuticals 40 CFR 266 Subpart P",
          "source": "RCRA hazardous waste generator standards 40 CFR Part 262; hazardous waste pharmaceuticals 40 CFR 266 Subpart P",
          "url": "https://www.ecfr.gov/current/title-40/part-262"
        },
        {
          "kind": "statute",
          "label": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "source": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. (CDPH); DTSC hazardous waste rules (22 CCR)",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalWaste.aspx"
        },
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 — labeling, SDS access, satellite accumulation",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 — labeling, SDS access, satellite accumulation",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "regulation",
          "label": "EPA definition of silver-bearing photographic/x-ray fixer as a listed or characteristic hazardous waste — generator determination required before disposal",
          "source": "EPA definition of silver-bearing photographic/x-ray fixer as a listed or characteristic hazardous waste — generator determination required before disposal",
          "url": "https://www.epa.gov/hw/defining-hazardous-waste"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "env-009",
      "kind": "compliance",
      "materials": [
        "labeled hazardous-waste satellite accumulation container",
        "secondary containment tray",
        "nitrile gloves and eye protection",
        "safety data sheets (SDS) binder or digital SDS access",
        "hazardous waste manifest or licensed recycler pickup form",
        "silver recovery unit or sealed silver-bearing waste container (if film processing is still on site)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm what is being discarded: used lead foil packets (film x-ray only), spent fixer/developer, expired disinfectant or etchant concentrate, or another spent chemical. Check the product's safety data sheet for its hazardous-waste characteristics.\n\nWhy: Different streams have different legal handling paths — lead foil and silver-bearing fixer are commonly regulated as hazardous or universal waste even in an office that is a small-quantity generator overall.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Identify the waste stream generated",
          "why": "Different streams have different legal handling paths — lead foil and silver-bearing fixer are commonly regulated as hazardous or universal waste even in an office that is a small-quantity generator overall."
        },
        {
          "detail": "A fully digital-imaging office generates no lead foil or fixer/developer; confirm before routing further.",
          "forks": [
            {
              "advised": false,
              "goto": "s10",
              "id": "digital-only",
              "label": "Office is fully digital — no film waste generated"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "still-generates",
              "label": "Office still uses film or generates spent chemicals"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Does the office still generate this waste stream?"
        },
        {
          "detail": "Place lead foil in its own rigid, labeled container (never in regular trash or sharps). Place spent fixer/developer in a sealed, labeled silver-bearing waste container or feed it through an on-site silver recovery unit if the practice has one. Place spent disinfectant/solvent in its own compatible, labeled hazardous-waste container. Never mix waste streams in one container.\n\nWhy: Mixing incompatible chemicals can react dangerously, and mixed hazardous waste loses any exemption the individual stream might have had.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "labeled hazardous-waste satellite accumulation container",
            "secondary containment tray"
          ],
          "role": "sterilization-tech",
          "title": "Segregate into the correct labeled satellite container",
          "why": "Mixing incompatible chemicals can react dangerously, and mixed hazardous waste loses any exemption the individual stream might have had."
        },
        {
          "detail": "Write or affix a label identifying the waste type and the date accumulation began; keep the container closed except when actively adding waste.\n\nWhy: Hazardous Communication and generator rules require content identification and a start-of-accumulation date to establish how long the container has been in use.\n\nRecord: container label with waste type and start date, and where the container is stored",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Label the container with contents and accumulation start date",
          "why": "Hazardous Communication and generator rules require content identification and a start-of-accumulation date to establish how long the container has been in use."
        },
        {
          "detail": "Container is closed and upright; secondary containment tray is under it; storage area is away from heat, ignition sources and incompatible chemicals; area is not accessible to patients.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Confirm safe storage conditions"
        },
        {
          "detail": "Is the container full or has it reached the accumulation time limit?",
          "forks": [
            {
              "advised": false,
              "goto": "s11",
              "id": "not-yet",
              "label": "Container has capacity and time remaining — continue accumulating"
            },
            {
              "advised": true,
              "goto": "s7",
              "id": "ready",
              "label": "Container is full or the accumulation time limit is approaching"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the container full or has it reached the accumulation time limit?"
        },
        {
          "detail": "Contact the practice's licensed hazardous waste hauler, universal waste recycler, or silver recovery vendor to schedule pickup or arrange a drop-off. Confirm the vendor is permitted to accept the specific waste stream.\n\nWhy: Only a licensed transporter/disposal facility may legally take custody of regulated hazardous waste.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "hazardous waste manifest or licensed recycler pickup form"
          ],
          "role": "compliance-officer",
          "title": "Arrange pickup or drop-off with a licensed hazardous waste hauler or recycler",
          "why": "Only a licensed transporter/disposal facility may legally take custody of regulated hazardous waste."
        },
        {
          "detail": "Complete and sign the hazardous waste manifest (or recycler receipt for exempt/universal waste streams) and file it in the compliance binder or digital record for at least three years.\n\nRecord: signed manifest or recycler receipt, filed with weight/volume, hauler name and pickup date",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Sign and retain the manifest or pickup receipt"
        },
        {
          "detail": "Hazardous waste stream removed by a licensed hauler with manifest on file",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hazardous waste stream removed by a licensed hauler with manifest on file"
        },
        {
          "detail": "Skip lead foil and silver-fixer steps entirely; continue at segregation for any spent disinfectant, etchant or solvent only.\n\nWhy: No point running steps for a waste stream the practice does not produce; this keeps the record accurate.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Route only spent disinfectants/solvents through this protocol",
          "why": "No point running steps for a waste stream the practice does not produce; this keeps the record accurate."
        },
        {
          "detail": "Container continues accumulating under labeled, contained storage",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Container continues accumulating under labeled, contained storage"
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Hazardous waste handling — lead foil, fixer and developer silver, spent disinfectants and solvents — A container of lead foil, used fixer or expired chemical is ready for disposal.",
      "title": "Hazardous waste handling — lead foil, fixer and developer silver, spent disinfectants and solvents",
      "trigger": "A container of lead foil, used fixer or expired chemical is ready for disposal",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices)",
          "source": "EPA Dental Office Category rule 40 CFR Part 441 (amalgam separators, best management practices)",
          "url": "https://www.ecfr.gov/current/title-40/part-441"
        },
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200; EPA mercury spill cleanup guidance for small spills",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200; EPA mercury spill cleanup guidance for small spills",
          "url": "https://www.epa.gov/mercury/cleaning-small-mercury-spills"
        },
        {
          "kind": "generic",
          "label": "ADA best-practice amalgam handling guidance — never use a household vacuum or heat source on mercury or amalgam scrap (generic functional equivalent restated, no reproduced text)",
          "source": "ADA best-practice amalgam handling guidance — never use a household vacuum or heat source on mercury or amalgam scrap (generic functional equivalent restated, no reproduced text)"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "env-010",
      "kind": "compliance",
      "materials": [
        "mercury spill kit (mercury absorbent powder or amalgamating spill kit, index card or cardboard, disposable gloves, sealable container, respirator if elemental mercury)",
        "nitrile gloves",
        "labeled amalgam/mercury waste container",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Small: a capsule or a few scraps of solid amalgam. Large: pooled liquid mercury, a spill that has spread, or an unknown/uncertain quantity.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "small",
              "label": "Small, contained solid-scrap or capsule spill"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "large",
              "label": "Large or liquid elemental mercury spill, or quantity unknown"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "assistant",
          "title": "Is this a small contained spill (one capsule/scrap) or a large spill (broken thermometer-scale elemental mercury, or unknown quantity)?"
        },
        {
          "detail": "Ask any patient in the chair to step back if needed, don nitrile gloves, and keep others from walking through the spill.\n\nWhy: Prevents tracking scrap or mercury on shoes and clothing to other parts of the office.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Clear the immediate area and put on gloves",
          "why": "Prevents tracking scrap or mercury on shoes and clothing to other parts of the office."
        },
        {
          "detail": "Never vacuum, sweep, or apply heat to mercury or amalgam scrap — a standard vacuum aerosolizes mercury vapor and heat increases vaporization.\n\nWhy: Vacuuming or heating mercury turns a contained spill into an inhalation hazard spread through the HVAC or room air.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Do not use a household or shop vacuum, broom, or any heat source",
          "why": "Vacuuming or heating mercury turns a contained spill into an inhalation hazard spread through the HVAC or room air."
        },
        {
          "detail": "Use the mercury spill kit's absorbent powder, sponge, or index-card-and-cardboard method to gather all visible scrap and droplets into the kit's sealable container. Check cracks and crevices where scrap can hide.\n\nWhy: The spill kit is designed to bind mercury and prevent re-release; improvised tools (paper towel, tissue) can leave residue behind.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "mercury spill kit (mercury absorbent powder or amalgamating spill kit, index card or cardboard, disposable gloves, sealable container, respirator if elemental mercury)"
          ],
          "role": "assistant",
          "title": "Collect scrap using the mercury spill kit",
          "why": "The spill kit is designed to bind mercury and prevent re-release; improvised tools (paper towel, tissue) can leave residue behind."
        },
        {
          "detail": "Seal the collection container per the kit instructions and label it as amalgam or mercury waste; route it to the practice's designated amalgam/mercury waste container, never to regular or biohazard trash.\n\nWhy: Mixing recovered mercury waste into another stream defeats the point of a dedicated recycler pathway (see env-003).\n\nRecord: spill event logged with location, approximate quantity and cleanup method",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Seal and label the recovered material as amalgam/mercury waste",
          "why": "Mixing recovered mercury waste into another stream defeats the point of a dedicated recycler pathway (see env-003)."
        },
        {
          "detail": "Ventilate the affected area to the outside per EPA small-spill guidance — this is an extended window measured in hours, not minutes, and scales with spill size — before treating the operatory or lab as clear for normal use; keep the space closed to patients and staff for that period rather than applying a fixed short timer.\n\nWhy: EPA's small-spill cleanup guidance calls for a materially longer ventilation window than a brief timer would suggest; residual mercury vapor is the exposure risk this step controls, and understating the window is a safety-relevant error, not a stylistic one.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Ventilate the area for an extended period before returning it to use",
          "why": "EPA's small-spill cleanup guidance calls for a materially longer ventilation window than a brief timer would suggest; residual mercury vapor is the exposure risk this step controls, and understating the window is a safety-relevant error, not a stylistic one."
        },
        {
          "detail": "Record what happened, where, who responded, cleanup method used, and disposal routing in the facility incident log.\n\nRecord: incident log entry: date, location, material, response, disposal route",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the spill in the incident record"
        },
        {
          "detail": "Small spill cleaned, waste routed to amalgam/mercury recycling, area cleared for use",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Small spill cleaned, waste routed to amalgam/mercury recycling, area cleared for use"
        },
        {
          "detail": "Move patients and staff out of the immediate area, open windows or increase ventilation if possible, and do not attempt cleanup of a large or liquid elemental mercury spill without a professional remediation contractor — contact one before proceeding.\n\nWhy: Elemental mercury vapor is a health hazard and large spills exceed what routine office supplies can safely contain.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Clear and ventilate the area before any cleanup attempt.",
            "role": "office-manager or compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "office-manager",
          "title": "Clear and ventilate the area before any cleanup attempt",
          "why": "Elemental mercury vapor is a health hazard and large spills exceed what routine office supplies can safely contain."
        },
        {
          "detail": "Large spill handed to a professional remediation contractor; area stays closed until cleared",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Large spill handed to a professional remediation contractor; area stays closed until cleared"
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Mercury or amalgam scrap spill cleanup — An amalgam capsule ruptures, or scrap or elemental mercury is spilled on the floor or counter.",
      "title": "Mercury or amalgam scrap spill cleanup",
      "trigger": "An amalgam capsule ruptures, or scrap or elemental mercury is spilled on the floor or counter",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS access, spill response information)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS access, spill response information)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens 29 CFR 1910.1030(d)(4)(iii) regulated waste containment principles applied to chemical spill debris disposal",
          "source": "OSHA Bloodborne Pathogens 29 CFR 1910.1030(d)(4)(iii) regulated waste containment principles applied to chemical spill debris disposal",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "regulation",
          "label": "OSHA emergency eyewash and shower access 29 CFR 1910.151(c) (incorporating ANSI Z358.1 by reference)",
          "source": "OSHA emergency eyewash and shower access 29 CFR 1910.151(c) (incorporating ANSI Z358.1 by reference)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.151"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "env-011",
      "kind": "compliance",
      "materials": [
        "safety data sheet (SDS) for the spilled product",
        "spill kit (absorbent pads/granules, neutralizer if applicable, gloves, eye protection, apron)",
        "eyewash station",
        "hazardous waste bag or labeled container for spill debris",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "office-manager",
        "compliance-officer",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "If the chemical splashed into eyes or on skin, go directly to the eyewash station or nearest sink and flush immediately for at least 15 minutes while someone else calls 911 if the exposure is severe, ingested, or involves a corrosive agent per the SDS; do not delay flushing to begin cleanup.\n\nWhy: Chemical exposure to eyes or skin is a time-sensitive injury — dilution and flushing must happen before spill containment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Check for eye or skin contact with the chemical before anything else.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Check for eye or skin contact with the chemical before anything else",
          "why": "Chemical exposure to eyes or skin is a time-sensitive injury — dilution and flushing must happen before spill containment."
        },
        {
          "detail": "Did anyone have eye or skin exposure requiring flushing?",
          "forks": [
            {
              "advised": false,
              "goto": "s11",
              "id": "yes-exposure",
              "label": "Yes — a person was exposed and is being flushed/treated"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "no-exposure",
              "label": "No exposure — proceed to spill containment"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did anyone have eye or skin exposure requiring flushing?"
        },
        {
          "detail": "Identify the product and pull its SDS to confirm required PPE, whether the spill can be neutralized, and disposal guidance.\n\nWhy: Different chemicals (bleach-based disinfectant vs phosphoric-acid etchant vs glutaraldehyde sterilant) need different neutralization and PPE — guessing risks a bad reaction.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "safety data sheet (SDS) for the spilled product"
          ],
          "role": "sterilization-tech",
          "title": "Check the safety data sheet for the spilled product",
          "why": "Different chemicals (bleach-based disinfectant vs phosphoric-acid etchant vs glutaraldehyde sterilant) need different neutralization and PPE — guessing risks a bad reaction."
        },
        {
          "detail": "Don gloves, eye protection and an apron as the SDS specifies; open windows or increase room ventilation before beginning cleanup.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Put on PPE per the SDS and increase ventilation"
        },
        {
          "detail": "Use the spill kit's absorbent material to ring and then cover the spill, working from the outside in; apply neutralizer only if the SDS confirms it is appropriate for this chemical.\n\nWhy: Working from the outside in prevents the spill from spreading further while it is absorbed.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "spill kit (absorbent pads/granules, neutralizer if applicable, gloves, eye protection, apron)"
          ],
          "role": "sterilization-tech",
          "title": "Contain and absorb the spill",
          "why": "Working from the outside in prevents the spill from spreading further while it is absorbed."
        },
        {
          "detail": "Sweep or scoop the absorbed material into a labeled hazardous waste bag or container appropriate to the chemical per its SDS.\n\nRecord: spill debris routed to the correct waste stream per SDS guidance",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Collect and bag the spill debris"
        },
        {
          "detail": "Wipe down the affected surface with water or the cleaner the SDS recommends, then dry the area before returning equipment to it.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Clean and dry the surface"
        },
        {
          "detail": "Compliance officer confirms the incident report accurately reflects whether anyone had eye or skin exposure, that flushing or EMS care was completed when applicable, and that the correct disposal route was used, before the incident is closed out.\n\nWhy: A chemical spill with confirmed eye or skin exposure is an OSHA-recordable-adjacent event and needs a documented, reviewed closure regardless of outcome, mirroring the sharps-container compliance gate (env-008).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews the incident before the record is closed.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews the incident before the record is closed",
          "why": "A chemical spill with confirmed eye or skin exposure is an OSHA-recordable-adjacent event and needs a documented, reviewed closure regardless of outcome, mirroring the sharps-container compliance gate (env-008)."
        },
        {
          "detail": "Record the chemical, quantity, cause, response, any exposure and outcome, and disposal routing in the facility incident log.\n\nRecord: incident log entry: date, chemical, quantity, cause, response, exposure (if any), disposal route",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the spill in the incident record"
        },
        {
          "detail": "Spill contained, debris disposed per SDS, area cleared for use, incident logged",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Spill contained, debris disposed per SDS, area cleared for use, incident logged"
        },
        {
          "detail": "Continue supporting the affected person until flushing is complete and, if 911 was called, until EMS arrives or clears the person. Only then return staff to spill containment.\n\nWhy: Person safety always precedes property/material cleanup.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete first aid before returning to spill cleanup",
          "why": "Person safety always precedes property/material cleanup."
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Chemical spill (disinfectant, sterilant, etchant, solvent) cleanup — A container of disinfectant, high-level sterilant, phosphoric acid or solvent breaks or overturns.",
      "title": "Chemical spill (disinfectant, sterilant, etchant, solvent) cleanup",
      "trigger": "A container of disinfectant, high-level sterilant, phosphoric acid or solvent breaks or overturns",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 — unidentified/unlabeled hazardous materials must be treated as hazardous until determined otherwise",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 — unidentified/unlabeled hazardous materials must be treated as hazardous until determined otherwise",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "911 / local fire department as the public first responder for suspected gas leaks and unknown hazardous materials — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "911 / local fire department as the public first responder for suspected gas leaks and unknown hazardous materials"
          },
          "source": "911 / local fire department as the public first responder for suspected gas leaks and unknown hazardous materials — Practice policy — no published authority governs this step."
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "env-012",
      "kind": "compliance",
      "materials": [
        "incident log",
        "evacuation route signage / staff evacuation plan",
        "phone for 911"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "compliance-officer",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the odor smells like natural gas or sulfur (rotten eggs), or if anyone feels dizzy, nauseated or short of breath, call 911 immediately, evacuate everyone from the building, and do not touch light switches, phones or anything that could spark.\n\nWhy: A suspected gas leak is a life-safety emergency where evacuation and 911 come before any investigation — sparks or delay can be catastrophic.",
          "gate": {
            "ack": "I confirm I have completed this step as written: If a gas leak is suspected, call 911 and evacuate immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "If a gas leak is suspected, call 911 and evacuate immediately",
          "why": "A suspected gas leak is a life-safety emergency where evacuation and 911 come before any investigation — sparks or delay can be catastrophic."
        },
        {
          "detail": "Is a gas leak suspected?",
          "forks": [
            {
              "advised": false,
              "goto": "s9",
              "id": "gas-yes",
              "label": "Yes — gas odor or symptoms present"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "gas-no",
              "label": "No — an unlabeled substance or a non-gas odor was found"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a gas leak suspected?"
        },
        {
          "detail": "Leave the item where it is, keep others away, and avoid direct contact or close inhalation while it is assessed.\n\nWhy: An unidentified substance is treated as hazardous until proven otherwise; direct contact or inhalation before identification risks exposure.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Do not touch, taste, smell closely, or move the unknown substance",
          "why": "An unidentified substance is treated as hazardous until proven otherwise; direct contact or inhalation before identification risks exposure."
        },
        {
          "detail": "Move people away from the item or odor source and increase ventilation if it can be done safely without approaching the substance.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Clear patients and non-essential staff from the immediate area"
        },
        {
          "detail": "Can the substance be identified with reasonable confidence (e.g. it matches a known product left out of its container)?",
          "forks": [
            {
              "advised": false,
              "goto": "s10",
              "id": "identified",
              "label": "Identified — matches a known office product"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "unidentified",
              "label": "Cannot be confidently identified"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Can the substance be identified with reasonable confidence (e.g. it matches a known product left out of its container)?"
        },
        {
          "detail": "If the substance cannot be identified and there is no immediate danger sign (no odor, no symptoms), call the local fire department's non-emergency hazmat line or 800-222-1222 (poison control) for guidance on safe handling.\n\nWhy: A calm, unidentified substance with no danger signs still needs an authoritative disposal opinion before staff handle it.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Call the fire department non-emergency line or poison control for guidance",
          "why": "A calm, unidentified substance with no danger signs still needs an authoritative disposal opinion before staff handle it."
        },
        {
          "detail": "Record what was found, where, who was notified, and how it was resolved in the facility incident log.\n\nRecord: incident log entry: date, item/odor description, location, notification made, resolution",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the discovery and resolution"
        },
        {
          "detail": "Substance identified and disposed per its protocol, or handled per outside guidance; incident logged",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Substance identified and disposed per its protocol, or handled per outside guidance; incident logged"
        },
        {
          "detail": "Building evacuated, 911 notified, area handed to first responders",
          "id": "s9",
          "kind": "step",
          "role": "ems",
          "title": "Building evacuated, 911 notified, area handed to first responders"
        },
        {
          "detail": "Once confidently identified, hand off to the appropriate protocol (chemical spill, mercury/amalgam spill, or hazardous waste handling) for cleanup and disposal.\n\nWhy: No need to escalate further once the substance is known and the correct protocol can take over.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Route to the matching spill or waste protocol",
          "why": "No need to escalate further once the substance is known and the correct protocol can take over."
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Unknown substance, powder or strong odor found in the office — Staff finds an unlabeled liquid or powder, or notices a chemical or gas odor of unknown origin — a suspected gas leak goes to 911.",
      "title": "Unknown substance, powder or strong odor found in the office",
      "trigger": "Staff finds an unlabeled liquid or powder, or notices a chemical or gas odor of unknown origin — a suspected gas leak goes to 911",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens 29 CFR 1910.1030(d)(4)(iii) — extracted teeth are regulated waste unless returned to the patient",
          "source": "OSHA Bloodborne Pathogens 29 CFR 1910.1030(d)(4)(iii) — extracted teeth are regulated waste unless returned to the patient",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "statute",
          "label": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. — extracted teeth containing amalgam handled as amalgam/medical waste, not general regulated waste, when discarded",
          "source": "California Medical Waste Management Act, Health & Safety Code §117600 et seq. — extracted teeth containing amalgam handled as amalgam/medical waste, not general regulated waste, when discarded",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/MedicalWaste.aspx"
        },
        {
          "kind": "generic",
          "label": "OSHA/CDC guidance: teeth returned to a patient are not considered regulated medical waste once released to them (generic functional equivalent restated, no reproduced text)",
          "source": "OSHA/CDC guidance: teeth returned to a patient are not considered regulated medical waste once released to them (generic functional equivalent restated, no reproduced text)"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "env-013",
      "kind": "compliance",
      "materials": [
        "clean sealed container or bag (for return to patient)",
        "regulated medical waste container (for disposal, if not returned or sent to a lab)",
        "disinfectant/decontamination solution (for a tooth being returned to the patient without amalgam)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Before or immediately after extraction, confirm whether the patient wants the extracted tooth back — common for pediatric patients or for religious/personal reasons.\n\nWhy: Once discarded into regulated waste a tooth cannot be retrieved, so the ask happens before disposal routing.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Ask whether the patient (or parent/guardian for a minor) wants the tooth returned",
          "why": "Once discarded into regulated waste a tooth cannot be retrieved, so the ask happens before disposal routing."
        },
        {
          "detail": "Does the tooth contain amalgam restoration material?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-amalgam",
              "label": "No amalgam present"
            },
            {
              "advised": false,
              "goto": "s6",
              "id": "has-amalgam",
              "label": "Amalgam present"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the tooth contain amalgam restoration material?"
        },
        {
          "detail": "Does the patient want the tooth returned?",
          "forks": [
            {
              "advised": false,
              "goto": "s7",
              "id": "return-yes",
              "label": "Yes — return to patient"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "return-no",
              "label": "No — dispose or send to lab"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the patient want the tooth returned?"
        },
        {
          "detail": "If not returned and not needed for lab analysis, place the tooth in the regulated medical waste (sharps/biohazard) container per the biohazard-and-sharps-waste-pickup protocol; if a lab referral requested the specimen, package and label it per the lab's specimen instructions instead.\n\nWhy: A discarded, non-amalgam extracted tooth is regulated medical waste under OSHA bloodborne pathogens rules once it leaves the patient's control.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "regulated medical waste container (for disposal, if not returned or sent to a lab)"
          ],
          "role": "assistant",
          "title": "Place the tooth in regulated medical waste (or send to a lab if requested for a diagnostic purpose)",
          "why": "A discarded, non-amalgam extracted tooth is regulated medical waste under OSHA bloodborne pathogens rules once it leaves the patient's control."
        },
        {
          "detail": "Tooth routed to regulated medical waste or sent to lab per specimen instructions",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Tooth routed to regulated medical waste or sent to lab per specimen instructions"
        },
        {
          "detail": "If the patient wants it back, note that the tooth contains a metal filling and hand it to them as-is; otherwise place it in the amalgam/mercury waste stream (see env-003), never in general regulated medical waste.\n\nWhy: Amalgam waste has its own recycling pathway under the EPA dental office rule — mixing it into medical waste both misroutes a recyclable material and can contaminate biohazard waste with mercury.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Route an amalgam-containing tooth to amalgam waste unless it is being returned to the patient",
          "why": "Amalgam waste has its own recycling pathway under the EPA dental office rule — mixing it into medical waste both misroutes a recyclable material and can contaminate biohazard waste with mercury."
        },
        {
          "detail": "Rinse visible blood/debris from the tooth, place it in a small clean, sealed container or bag, and hand it directly to the patient or parent/guardian before they leave.\n\nWhy: Once released to the patient, the tooth is their personal property and is no longer regulated medical waste; use a plain clean container rather than biohazard labeling, which is reserved for the disposal path (env-013 step-dispose) and would misrepresent a returned item — often to a child, for tooth-fairy purposes — as still-hazardous waste.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "clean sealed container or bag (for return to patient)"
          ],
          "role": "assistant",
          "title": "Decontaminate and package the tooth for the patient",
          "why": "Once released to the patient, the tooth is their personal property and is no longer regulated medical waste; use a plain clean container rather than biohazard labeling, which is reserved for the disposal path (env-013 step-dispose) and would misrepresent a returned item — often to a child, for tooth-fairy purposes — as still-hazardous waste."
        },
        {
          "detail": "Document that the extracted tooth was returned to the patient (or parent/guardian) at the visit.\n\nRecord: chart note: extracted tooth returned to patient/guardian on date of extraction",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Note the return in the patient's chart"
        },
        {
          "detail": "Tooth returned to patient/guardian; chart noted",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Tooth returned to patient/guardian; chart noted"
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Extracted teeth handling, patient return request and disposal — A tooth is extracted and the patient asks to keep it, or teeth accumulate for disposal.",
      "title": "Extracted teeth handling, patient return request and disposal",
      "trigger": "A tooth is extracted and the patient asks to keep it, or teeth accumulate for disposal",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Electronic Waste Recycling Act (Public Resources Code §42460 et seq.) and Universal Waste Rule (22 CCR Division 4.5, Chapter 23) — covered electronic devices, batteries and fluorescent lamps managed as universal waste",
          "source": "California Electronic Waste Recycling Act (Public Resources Code §42460 et seq.) and Universal Waste Rule (22 CCR Division 4.5, Chapter 23) — covered electronic devices, batteries and fluorescent lamps managed as universal waste",
          "url": "https://dtsc.ca.gov/universal-waste/"
        },
        {
          "kind": "regulation",
          "label": "EPA Universal Waste Rule 40 CFR Part 273 — batteries, lamps and electronics as universal waste with simplified handling requirements",
          "source": "EPA Universal Waste Rule 40 CFR Part 273 — batteries, lamps and electronics as universal waste with simplified handling requirements",
          "url": "https://www.ecfr.gov/current/title-40/part-273"
        }
      ],
      "class": "environmental-biomedical-waste",
      "department": "facility",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "env-014",
      "kind": "compliance",
      "materials": [
        "labeled e-waste/battery collection bin",
        "data-wipe checklist for any device holding stored data",
        "shipping box or recycler drop-off container"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm what is being disposed of: a monitor/computer/sensor, a rechargeable or button battery, or a fluorescent/mercury-containing lamp.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the item being retired"
        },
        {
          "detail": "Does the item store data (computer, sensor, tablet, imaging device)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "holds-data",
              "label": "Yes — device stores or may store practice/patient data"
            },
            {
              "advised": false,
              "goto": "s5",
              "id": "no-data",
              "label": "No — battery, lamp, or a device with no stored data"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Does the item store data (computer, sensor, tablet, imaging device)?"
        },
        {
          "detail": "Perform a certified data wipe (or physical destruction of the storage media) on any device that may hold practice management data, images, or other stored information before it leaves the office.\n\nWhy: A retired device is an on-device data exposure risk per the practice's PHI-on-device rule — data must be wiped before the device changes hands.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "data-wipe checklist for any device holding stored data"
          ],
          "role": "it-vendor",
          "title": "Wipe or destroy stored data before disposal",
          "why": "A retired device is an on-device data exposure risk per the practice's PHI-on-device rule — data must be wiped before the device changes hands."
        },
        {
          "detail": "Record the device identifier (asset tag, not patient data), wipe method, date, and who performed it.\n\nRecord: IT asset log: device retired, wipe method and date, performed by",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the data wipe"
        },
        {
          "detail": "Put the retired electronic device, battery, or lamp in its labeled collection container, keeping batteries and lamps separated from general electronics if the recycler requires it.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "labeled e-waste/battery collection bin"
          ],
          "role": "office-manager",
          "title": "Place the item in the labeled universal waste collection bin"
        },
        {
          "detail": "Is a universal waste recycler or take-back program already arranged?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "arranged",
              "label": "Yes — recycler/take-back program on file"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "not-arranged",
              "label": "No — need to identify one"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a universal waste recycler or take-back program already arranged?"
        },
        {
          "detail": "Arrange pickup by the recycler or drop the collected items off per the program's instructions, keeping any receipt provided.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "shipping box or recycler drop-off container"
          ],
          "role": "office-manager",
          "title": "Schedule pickup or drop off at the recycler"
        },
        {
          "detail": "Item recycled through a certified universal waste channel; any data-bearing device wiped first",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Item recycled through a certified universal waste channel; any data-bearing device wiped first"
        },
        {
          "detail": "Locate a local certified electronics/battery/lamp recycler or a manufacturer take-back program and add it to the practice's vendor list for future use.\n\nWhy: Universal waste rules require routing to an authorized handler, not general trash — sourcing this once avoids repeating the search each time.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify a certified universal waste recycler or manufacturer take-back program",
          "why": "Universal waste rules require routing to an authorized handler, not general trash — sourcing this once avoids repeating the search each time."
        }
      ],
      "subclass": "environmental-and-biomedical-waste",
      "summary": "Electronic, battery and lamp waste disposal — A monitor, sensor, curing light battery or fluorescent lamp is retired.",
      "title": "Electronic, battery and lamp waste disposal",
      "trigger": "A monitor, sensor, curing light battery or fluorescent lamp is retired",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)",
          "source": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)"
        },
        {
          "kind": "regulation",
          "label": "No specific regulatory authority found for dental-equipment preventive-maintenance intervals — internal manufacturer/manual-driven maintenance schedule — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No specific regulatory authority found for dental-equipment preventive-maintenance intervals — internal manufacturer/manual-driven maintenance schedule — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.157 governs portable fire extinguisher placement/maintenance/testing; 1910.37 governs exit-route design and maintenance; 1910.151 governs first-aid/eyewash provisions for corrosive-exposure workplaces. None of these three sections mention compressors, vacuum filters, dental chairs, sensors, imaging equipment, or furnaces, or set any calibration/service-interval requirement for them.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.157 portable fire extinguishers; 1910.37 exit routes; 1910.151 eyewash",
              "url": null
            }
          },
          "source": "No specific regulatory authority found for dental-equipment preventive-maintenance intervals — internal manufacturer/manual-driven maintenance schedule — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 bloodborne pathogens — PPE before handling drain condensate or vacuum trap/filter contents that may carry oral fluids or biofilm",
          "source": "OSHA 29 CFR 1910.1030 bloodborne pathogens — PPE before handling drain condensate or vacuum trap/filter contents that may carry oral fluids or biofilm",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol6/xml/CFR-2024-title29-vol6-sec1910-1030.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "weekly",
      "id": "eqm-001",
      "kind": "operational",
      "materials": [
        "compressor tank drain valve access",
        "vacuum system solution or cleaner per manufacturer instructions for use",
        "inline trap/filter set",
        "log sheet or maintenance tracker",
        "gloves and eye protection"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the operatory schedule; do not shut down or drain a compressor while a handpiece or vacuum is in active use chairside.\n\nWhy: Interrupting suction or air mid-procedure disrupts patient care and can startle a seated patient.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the compressor and vacuum are powered and no patient is mid-procedure",
          "why": "Interrupting suction or air mid-procedure disrupts patient care and can startle a seated patient."
        },
        {
          "detail": "Don gloves and eye protection before opening the drain valve. Open the manual or automatic drain valve at the base of the compressor tank; let water and condensate fully drain into a catch container; close the valve.\n\nWhy: Moisture buildup in the tank corrodes the tank and can push water into the dental air supply lines; the condensate can carry oral fluids from the air supply, so PPE applies per OSHA 29 CFR 1910.1030.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "compressor tank drain valve access",
            "gloves and eye protection"
          ],
          "role": "assistant",
          "title": "Open the compressor tank drain valve and release condensation",
          "why": "Moisture buildup in the tank corrodes the tank and can push water into the dental air supply lines; the condensate can carry oral fluids from the air supply, so PPE applies per OSHA 29 CFR 1910.1030."
        },
        {
          "detail": "Read the gauge; compare to the range printed on the compressor's instructions for use or nameplate.\n\nWhy: A gauge reading outside the normal range signals a leak or valve failure before it causes a mid-day outage.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Check compressor tank pressure gauge against manufacturer's normal range",
          "why": "A gauge reading outside the normal range signals a leak or valve failure before it causes a mid-day outage."
        },
        {
          "detail": "Is the compressor operating within normal pressure and free of unusual noise or vibration?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "normal",
              "label": "Yes — normal operation"
            },
            {
              "goto": "s10",
              "id": "abnormal",
              "label": "No — abnormal pressure, noise, or vibration"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the compressor operating within normal pressure and free of unusual noise or vibration?"
        },
        {
          "detail": "Run the recommended cleaning/evacuation solution through each vacuum line per the instructions for use, typically at the end of the clinical day.\n\nWhy: Debris and biofilm in vacuum lines reduce suction and can clog the separator.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "vacuum system solution or cleaner per manufacturer instructions for use"
          ],
          "role": "assistant",
          "title": "Flush the vacuum system with the manufacturer-recommended solution",
          "why": "Debris and biofilm in vacuum lines reduce suction and can clog the separator."
        },
        {
          "detail": "Don gloves and eye protection before opening or handling the solids collector/trap. Check the solids collector/trap for fill level; check inline filters for discoloration or clogging; replace any trap or filter at or beyond its rated capacity or interval.\n\nWhy: Trap and filter contents carry oral fluids and biofilm — bloodborne pathogen PPE applies per OSHA 29 CFR 1910.1030.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "inline trap/filter set",
            "gloves and eye protection"
          ],
          "role": "assistant",
          "title": "Inspect and replace vacuum inline traps and filters as needed",
          "why": "Trap and filter contents carry oral fluids and biofilm — bloodborne pathogen PPE applies per OSHA 29 CFR 1910.1030."
        },
        {
          "detail": "Attach a saliva ejector or high-volume evacuator tip and confirm suction matches the practice's normal baseline.\n\nWhy: Confirms the maintenance restored effective suction rather than just completing the checklist.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Test suction strength at a representative operatory line",
          "why": "Confirms the maintenance restored effective suction rather than just completing the checklist."
        },
        {
          "detail": "Enter the date, compressor drain volume/pressure reading, vacuum trap/filter status, and any parts replaced into the equipment maintenance log or tracker.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Log the maintenance date, findings, and any parts replaced"
        },
        {
          "detail": "Weekly compressor and vacuum maintenance complete",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Weekly compressor and vacuum maintenance complete"
        },
        {
          "detail": "Report the specific abnormal reading (pressure, noise, vibration) and the operatory(ies) affected to the office manager so a service technician can be scheduled before the next clinical day, then continue with the independent weekly vacuum-system tasks below.\n\nWhy: The compressor and the vacuum system are separate lines — escalating a compressor problem must not skip the vacuum flush, trap inspection, and suction test, which are due this week regardless of compressor status.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Escalate abnormal readings to the office manager for a service call",
          "why": "The compressor and the vacuum system are separate lines — escalating a compressor problem must not skip the vacuum flush, trap inspection, and suction test, which are due this week regardless of compressor status."
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Weekly compressor drain and vacuum filter maintenance — The weekly maintenance day arrives, or the compressor drains water or the vacuum weakens.",
      "title": "Weekly compressor drain and vacuum filter maintenance",
      "trigger": "The weekly maintenance day arrives, or the compressor drains water or the vacuum weakens",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.151 medical services and first aid (eyewash)",
          "source": "OSHA 29 CFR 1910.151 medical services and first aid (eyewash)",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol5/xml/CFR-2024-title29-vol5-sec1910-151.xml"
        },
        {
          "kind": "open_standard",
          "label": "ANSI/ISEA Z358.1 emergency eyewash (open standard); Cal/OSHA Title 8 §5162",
          "source": "ANSI/ISEA Z358.1 emergency eyewash (open standard); Cal/OSHA Title 8 §5162",
          "url": "https://www.dir.ca.gov/title8/5162.html"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 10,
      "frequency": "weekly",
      "id": "eqm-002",
      "kind": "operational",
      "materials": [
        "eyewash station activation log",
        "clean absorbent cloth",
        "signage check"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Walk to the eyewash station; confirm nothing is stacked or stored in front of it and the ten-second, unobstructed-path standard is met.\n\nWhy: ANSI/ISEA Z358.1 calls for the station to be reachable within ten seconds of a chemical splash; a blocked path defeats the purpose.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Locate the eyewash station and confirm the path to it is unobstructed",
          "why": "ANSI/ISEA Z358.1 calls for the station to be reachable within ten seconds of a chemical splash; a blocked path defeats the purpose."
        },
        {
          "detail": "Lift or twist off the nozzle dust covers before activating the valve.\n\nWhy: Activating the valve with covers on can cause the covers to shoot off or block flow.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Remove protective dust covers from both nozzles",
          "why": "Activating the valve with covers on can cause the covers to shoot off or block flow."
        },
        {
          "detail": "Push or pull the activation handle to hands-free flow and let both streams run for at least one minute, checking water clarity, flow, and that both streams meet in the center.\n\nWhy: A weekly flush clears sediment and stagnant water and confirms the valve still opens in under one second, as the open standard requires.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Activate the valve and run the flush for at least one minute",
          "why": "A weekly flush clears sediment and stagnant water and confirms the valve still opens in under one second, as the open standard requires."
        },
        {
          "detail": "Do both streams flow clearly, evenly, and meet at the correct height?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "pass",
              "label": "Yes — flow, clarity, and alignment are correct"
            },
            {
              "goto": "s8",
              "id": "fail",
              "label": "No — weak flow, discoloration, or misalignment"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Do both streams flow clearly, evenly, and meet at the correct height?"
        },
        {
          "detail": "Return the valve to off and reseat both dust covers.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Shut off the valve and replace nozzle dust covers"
        },
        {
          "detail": "Enter the date, pass result, and staff initials on the eyewash station activation log kept at or near the station.\n\nRecord: eyewash station activation log",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Log the activation date, flow result, and initials"
        },
        {
          "detail": "Weekly eyewash activation and log complete",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Weekly eyewash activation and log complete"
        },
        {
          "detail": "Notify the compliance officer of the specific defect (weak flow, discoloration, misalignment) so plumbing or the station can be serviced before the next clinical day; mark the station out-of-service if flow is inadequate.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Report the failed activation to the compliance officer immediately"
        },
        {
          "detail": "After plumbing or service work is reported complete, repeat the one-minute activation flush and re-check flow, clarity, and alignment before the station is returned to normal service.\n\nWhy: A station marked out-of-service must not silently return to use (or stay flagged) without a confirming re-test, unlike a fix that is simply assumed to have worked.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Once repaired, re-run the activation flush before removing the out-of-service tag",
          "why": "A station marked out-of-service must not silently return to use (or stay flagged) without a confirming re-test, unlike a fix that is simply assumed to have worked."
        },
        {
          "detail": "Does the re-test now pass (flow, clarity, and alignment correct)?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "pass",
              "label": "Yes — re-test passes; remove the out-of-service tag"
            },
            {
              "goto": "s8",
              "id": "fail",
              "label": "No — still fails; keep the station out-of-service"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the re-test now pass (flow, clarity, and alignment correct)?"
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Emergency eyewash station weekly activation and log — The weekly safety walk-through, or the station was used after a splash.",
      "title": "Emergency eyewash station weekly activation and log",
      "trigger": "The weekly safety walk-through, or the station was used after a splash",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.157 portable fire extinguishers",
          "source": "OSHA 29 CFR 1910.157 portable fire extinguishers",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol5/xml/CFR-2024-title29-vol5-sec1910-157.xml"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.37 exit routes",
          "source": "OSHA 29 CFR 1910.37 exit routes",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol5/xml/CFR-2024-title29-vol5-sec1910-37.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 25,
      "frequency": "monthly",
      "id": "eqm-003",
      "kind": "operational",
      "materials": [
        "fire extinguisher inspection tag",
        "flashlight",
        "monthly inspection log",
        "step stool for exit sign checks"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Visit every mounted extinguisher, including operatories, break room, sterilization area, and business office.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Walk to each fire extinguisher location in the facility"
        },
        {
          "detail": "Confirm the pressure gauge needle is in the green zone, the pin and tamper seal are intact, the extinguisher is visibly undamaged, and nothing blocks access to it.\n\nWhy: A discharged, damaged, or blocked extinguisher is unusable in an actual fire.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Check each extinguisher's gauge, pin, seal, and accessibility",
          "why": "A discharged, damaged, or blocked extinguisher is unusable in an actual fire."
        },
        {
          "detail": "Sign and date the monthly inspection tag hanging on each extinguisher that passed.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "fire extinguisher inspection tag"
          ],
          "role": "office-manager",
          "title": "Initial and date the extinguisher's inspection tag"
        },
        {
          "detail": "Confirm every exit sign is lit and readable; where the fixture has a test button, press it and confirm the unit switches to battery power and stays lit.\n\nWhy: Exit lighting must remain functional during a power failure so occupants can find the way out.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Test each illuminated exit sign and emergency light",
          "why": "Exit lighting must remain functional during a power failure so occupants can find the way out."
        },
        {
          "detail": "Confirm no furniture, boxes, or equipment obstruct any exit route, and every exit door opens freely from the inside without a key or special knowledge.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Walk each posted exit route and confirm it is clear and unlocked from the inside"
        },
        {
          "detail": "Did every extinguisher, exit light, and exit route pass?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pass",
              "label": "Yes — all items pass"
            },
            {
              "goto": "s9",
              "id": "fail",
              "label": "No — one or more items failed"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did every extinguisher, exit light, and exit route pass?"
        },
        {
          "detail": "Enter the date, items checked, and initials into the monthly fire/exit inspection log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the monthly check as complete with date and initials"
        },
        {
          "detail": "Monthly fire, exit and alarm check complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Monthly fire, exit and alarm check complete"
        },
        {
          "detail": "A discharged extinguisher, dead exit light, or blocked/locked exit is a regulatory and life-safety gap and needs sign-off that it is corrected or the area is temporarily restricted before clinic reopens.\n\nWhy: A blocked or locked emergency exit or a dead extinguisher can turn a minor incident into a life-safety failure, so a named person confirms the fix before normal operations resume.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route the failed item to the compliance officer for immediate correction.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Route the failed item to the compliance officer for immediate correction",
          "why": "A blocked or locked emergency exit or a dead extinguisher can turn a minor incident into a life-safety failure, so a named person confirms the fix before normal operations resume."
        },
        {
          "detail": "Enter the failed item, the corrective action taken (recharge, replacement, unblocking), the date corrected, and the compliance officer's sign-off into the monthly log.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the failed item, the fix applied, and who signed off"
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Fire extinguisher, exit lighting and alarm monthly check — The first business day of the month, or a fire-marshal inspection is scheduled.",
      "title": "Fire extinguisher, exit lighting and alarm monthly check",
      "trigger": "The first business day of the month, or a fire-marshal inspection is scheduled",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III accessible path and signage (28 CFR Part 36)",
          "source": "ADA Title III accessible path and signage (28 CFR Part 36)",
          "url": "https://www.ada.gov/resources/title-iii-primer/"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.37 exit routes",
          "source": "OSHA 29 CFR 1910.37 exit routes",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol5/xml/CFR-2024-title29-vol5-sec1910-37.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "eqm-004",
      "kind": "operational",
      "materials": [
        "facility walkthrough checklist",
        "camera or phone for hazard photos",
        "monthly walkthrough log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Use the standing checklist covering floors, signage, restrooms, waiting area, and the accessible path from parking or the street.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "facility walkthrough checklist"
          ],
          "role": "office-manager",
          "title": "Print or open the facility walkthrough checklist"
        },
        {
          "detail": "Check for loose flooring, torn carpet edges, cords across walkways, wet floors, and uneven thresholds in the waiting room, hallways, and operatories.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Inspect floors and common areas for trip hazards"
        },
        {
          "detail": "Check the path of travel from parking/street to the entrance and through the office for width, ramp condition, door hardware operable with a closed fist, and no obstructions.\n\nWhy: The ADA Title III accessible-path requirement applies to the whole path of travel, not just the entrance door.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the accessible path from the entrance is unobstructed and code-compliant",
          "why": "The ADA Title III accessible-path requirement applies to the whole path of travel, not just the entrance door."
        },
        {
          "detail": "Confirm soap, paper towels/dryer, toilet paper are stocked, fixtures do not leak, and grab bars (where present) are secure.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Check restrooms for cleanliness, supplies, and functioning fixtures"
        },
        {
          "detail": "Check that OSHA, accessible-entrance, exit, and any required notices are posted, unfaded, and not obscured.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm required signage is posted, legible, and current"
        },
        {
          "detail": "Were any hazards or deficiencies found?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "none",
              "label": "No — no hazards found"
            },
            {
              "goto": "s9",
              "id": "found",
              "label": "Yes — one or more hazards found"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Were any hazards or deficiencies found?"
        },
        {
          "detail": "Enter the date and 'no findings' into the monthly walkthrough log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the walkthrough as complete with no findings"
        },
        {
          "detail": "Monthly facility walkthrough complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Monthly facility walkthrough complete"
        },
        {
          "detail": "Take a photo of each hazard and note its exact location on the checklist.",
          "id": "s9",
          "kind": "step",
          "materials": [
            "camera or phone for hazard photos"
          ],
          "role": "office-manager",
          "title": "Photograph and document each hazard found"
        },
        {
          "detail": "Route each item to the appropriate person (maintenance vendor, janitorial service, front desk) with a specific correction deadline, prioritizing anything that blocks an exit or the accessible path.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign each hazard to a responsible party with a correction deadline"
        },
        {
          "detail": "Does any hazard found block an exit route or the accessible path?",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "no",
              "label": "No — hazards found do not block an exit or the accessible path"
            },
            {
              "goto": "s13",
              "id": "yes",
              "label": "Yes — one or more hazards block an exit route or the accessible path"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does any hazard found block an exit route or the accessible path?"
        },
        {
          "detail": "Enter each hazard, who it was assigned to, the deadline, and the date it was verified corrected into the monthly walkthrough log.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Log each hazard, assignee, deadline, and correction date once closed"
        },
        {
          "detail": "A hazard blocking an exit route or the ADA accessible path is a life-safety and accessibility gap; the compliance officer confirms it is corrected, or the affected area is temporarily restricted, before normal operations continue.\n\nWhy: A blocked or obstructed exit or accessible path can turn a minor facility issue into a life-safety or accessibility failure, so a named person confirms the fix or restriction before the walkthrough closes out.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms the exit/accessible-path hazard is corrected or the area restricted.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms the exit/accessible-path hazard is corrected or the area restricted",
          "why": "A blocked or obstructed exit or accessible path can turn a minor facility issue into a life-safety or accessibility failure, so a named person confirms the fix or restriction before the walkthrough closes out."
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Monthly facility walkthrough (trip hazards, signage, restrooms, accessible path) — The monthly walkthrough date arrives, or a patient or staff member reports a hazard.",
      "title": "Monthly facility walkthrough (trip hazards, signage, restrooms, accessible path)",
      "trigger": "The monthly walkthrough date arrives, or a patient or staff member reports a hazard",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.37 exit routes; ADA Title III accessible path and signage (28 CFR Part 36)",
          "source": "OSHA 29 CFR 1910.37 exit routes; ADA Title III accessible path and signage (28 CFR Part 36)",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol5/xml/CFR-2024-title29-vol5-sec1910-37.xml"
        },
        {
          "kind": "generic",
          "label": "— no public regulatory floor governs routine janitorial audit cadence itself; based on standard facility-management practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent — no public regulatory floor governs routine janitorial audit cadence itself; based on standard facility-management practice"
          },
          "source": "— no public regulatory floor governs routine janitorial audit cadence itself; based on standard facility-management practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 15,
      "frequency": "weekly",
      "id": "eqm-005",
      "kind": "operational",
      "materials": [
        "janitorial service scope-of-work checklist",
        "weekly audit log",
        "camera or phone for issue photos"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Use the written scope of work from the janitorial contract or service agreement, listing every area and task the service is responsible for.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "janitorial service scope-of-work checklist"
          ],
          "role": "office-manager",
          "title": "Open the janitorial service's scope-of-work checklist"
        },
        {
          "detail": "Visit operatories, sterilization, restrooms, break room, reception, and hallways; confirm trash removal, surface cleaning, vacuuming/mopping, and restocking were completed per the scope.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Walk each area on the scope and check it against the task list"
        },
        {
          "detail": "Was the scope of work fully completed to an acceptable standard?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "pass",
              "label": "Yes — scope fully met"
            },
            {
              "goto": "s6",
              "id": "fail",
              "label": "No — one or more items missed or substandard"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was the scope of work fully completed to an acceptable standard?"
        },
        {
          "detail": "Enter the date, 'pass', and initials into the weekly janitorial audit log.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the audit as passed with date and initials"
        },
        {
          "detail": "Weekly janitorial audit complete",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Weekly janitorial audit complete"
        },
        {
          "detail": "Photograph the specific area and note what was missed or done poorly.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "camera or phone for issue photos"
          ],
          "role": "office-manager",
          "title": "Photograph and note each missed or substandard item"
        },
        {
          "detail": "Send the photos and notes to the vendor's point of contact and request correction before the next scheduled service.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Send the findings to the janitorial vendor for correction"
        },
        {
          "detail": "Enter the missed items, date the vendor was notified, and whether correction was confirmed into the weekly janitorial audit log.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the findings, vendor notified, and correction status"
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Janitorial service checklist and weekly audit — The weekly audit day arrives, or a cleanliness complaint is received.",
      "title": "Janitorial service checklist and weekly audit",
      "trigger": "The weekly audit day arrives, or a cleanliness complaint is received",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §5142 (ventilation) and FDA/manufacturer service-interval guidance",
          "source": "Cal/OSHA Title 8 §5142 (ventilation) and FDA/manufacturer service-interval guidance",
          "url": "https://www.dir.ca.gov/title8/5142.html"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "quarterly",
      "id": "eqm-006",
      "kind": "operational",
      "materials": [
        "replacement HVAC filters (correct size/MERV rating)",
        "thermostat/HVAC maintenance log",
        "step stool if needed for filter access"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Identify each air handler, return vent, or filter slot serving the office, including separate units for different zones.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Locate every HVAC filter access point in the facility"
        },
        {
          "detail": "Pull each filter and check for visible dust loading, discoloration, or damage; compare against the filter's rated replacement interval.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Inspect each current filter's condition"
        },
        {
          "detail": "Install new filters of the correct size and MERV rating, noting airflow direction arrows on the filter frame.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "replacement HVAC filters (correct size/MERV rating)"
          ],
          "role": "office-manager",
          "title": "Replace filters that are due or visibly loaded"
        },
        {
          "detail": "Adjust the thermostat set point briefly to confirm the system engages heating and cooling on command, then return to the normal schedule.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Check thermostat settings and confirm heating and cooling both respond"
        },
        {
          "detail": "Did all units change filters and respond correctly to the thermostat test?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "pass",
              "label": "Yes — all units serviced and responsive"
            },
            {
              "goto": "s8",
              "id": "fail",
              "label": "No — a unit failed to respond or has a persistent odor/airflow issue"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did all units change filters and respond correctly to the thermostat test?"
        },
        {
          "detail": "Enter the date, filter sizes/quantities replaced, and thermostat test result into the HVAC maintenance log.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the filter change date, sizes used, and test result"
        },
        {
          "detail": "HVAC filter change and air-quality check complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "HVAC filter change and air-quality check complete"
        },
        {
          "detail": "Call the HVAC service vendor, describe the specific symptom (no heat/cool response, odor, noise), and schedule a service visit.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule an HVAC service technician for the unresponsive or odor-producing unit"
        },
        {
          "detail": "Enter the symptom, date the vendor was contacted, and the scheduled service date into the HVAC maintenance log.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the issue, vendor contacted, and service appointment date"
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "HVAC filter change and air-quality check — The quarterly filter date arrives, or staff report stuffiness, odors or temperature drift.",
      "title": "HVAC filter change and air-quality check",
      "trigger": "The quarterly filter date arrives, or staff report stuffiness, odors or temperature drift",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)",
          "source": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "semi-annual",
      "id": "eqm-007",
      "kind": "operational",
      "materials": [
        "manufacturer instructions for use (chair and delivery unit)",
        "lubricant per manufacturer specification",
        "handpiece/lines cleaner per instructions for use",
        "semi-annual maintenance log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Block the operatory on the schedule for the estimated maintenance duration so no patient is booked into it.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the operatory out of the clinical calendar for the maintenance window"
        },
        {
          "detail": "Cycle the chair through up/down, recline, and base rotation per the instructions for use, listening and watching for grinding, hesitation, or uneven movement.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "manufacturer instructions for use (chair and delivery unit)"
          ],
          "role": "assistant",
          "title": "Test chair movement through its full range under manufacturer guidance"
        },
        {
          "detail": "Apply the specified lubricant to hinge points and tracks called out in the instructions for use, using only the specified type and amount.\n\nWhy: The wrong lubricant type or over-lubrication can damage seals or attract debris.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "lubricant per manufacturer specification"
          ],
          "role": "assistant",
          "title": "Lubricate moving parts per manufacturer specification",
          "why": "The wrong lubricant type or over-lubrication can damage seals or attract debris."
        },
        {
          "detail": "Run the waterline flush/cleaning cycle per the instructions for use and, where the practice's protocol calls for periodic waterline biological testing, collect the sample per that schedule.\n\nWhy: Dental unit waterlines can develop biofilm; periodic testing supports safe water quality for patient care.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "handpiece/lines cleaner per instructions for use"
          ],
          "role": "assistant",
          "title": "Flush and test delivery unit waterlines",
          "why": "Dental unit waterlines can develop biofilm; periodic testing supports safe water quality for patient care."
        },
        {
          "detail": "Inspect air and water hoses for cracking, check quick-connect couplers for secure seating, and check for any visible air or water leaks under normal operating pressure.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Check delivery unit hoses, connectors, and handpiece couplers for wear or leaks"
        },
        {
          "detail": "Did the chair, delivery unit, and waterlines all pass inspection?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pass",
              "label": "Yes — all systems pass"
            },
            {
              "goto": "s9",
              "id": "fail",
              "label": "No — a mechanical, hose, or waterline issue was found"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the chair, delivery unit, and waterlines all pass inspection?"
        },
        {
          "detail": "Enter the operatory, date, tasks completed, and pass result into the semi-annual maintenance log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the maintenance date, tasks performed, and pass result"
        },
        {
          "detail": "Chair and delivery unit preventive maintenance complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Chair and delivery unit preventive maintenance complete"
        },
        {
          "detail": "Contact the equipment service vendor with the specific finding, keep the operatory blocked from scheduling, and note the expected service date.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule a service technician and keep the operatory out of rotation until resolved"
        },
        {
          "detail": "Enter the finding, date reported, vendor, and the date the operatory was returned to service into the semi-annual maintenance log.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the issue, vendor contacted, and resolution date once corrected"
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Chair and delivery unit preventive maintenance — Semi-annual.",
      "title": "Chair and delivery unit preventive maintenance",
      "trigger": "Semi-annual",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use) — water heater and delivery-system water quality supports the same instructions-for-use floor",
          "source": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use) — water heater and delivery-system water quality supports the same instructions-for-use floor"
        },
        {
          "kind": "generic",
          "label": "Local water utility cross-connection control program and state plumbing code (generic — annual backflow-preventer testing by a certified tester is the near-universal municipal requirement)",
          "source": "Local water utility cross-connection control program and state plumbing code (generic — annual backflow-preventer testing by a certified tester is the near-universal municipal requirement)"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "annual",
      "id": "eqm-008",
      "kind": "operational",
      "materials": [
        "thermometer for water heater check",
        "annual test/inspection log",
        "backflow test certificate form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Check the utility's cross-connection control notice or the practice's own record for the required annual test date.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the annual backflow test deadline with the water utility or municipal record"
        },
        {
          "detail": "Book a state- or locally-certified backflow preventer tester, since most jurisdictions require the test be performed and certified by a licensed tester rather than office staff.\n\nWhy: Backflow preventer testing generally must be performed by a certified tester for the certificate to be accepted by the water utility.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "backflow preventer test kit (licensed tester's equipment)"
          ],
          "role": "office-manager",
          "title": "Schedule a certified backflow tester",
          "why": "Backflow preventer testing generally must be performed by a certified tester for the certificate to be accepted by the water utility."
        },
        {
          "detail": "Collect the completed test certificate showing pass/fail for each check valve and relief valve on the assembly.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the test results and certificate from the tester"
        },
        {
          "detail": "Measure hot water temperature at a nearby fixture and compare to the practice's target range, balancing scald-prevention against the temperature needed for effective handwashing and instrument-area use.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "thermometer for water heater check"
          ],
          "role": "office-manager",
          "title": "Check the water heater's set temperature with a thermometer"
        },
        {
          "detail": "Did the backflow preventer pass and is the water heater within the target temperature range?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "pass",
              "label": "Yes — both pass"
            },
            {
              "goto": "s9",
              "id": "fail",
              "label": "No — backflow failed or water heater is out of range"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the backflow preventer pass and is the water heater within the target temperature range?"
        },
        {
          "detail": "Send or upload the signed test certificate to the water utility's cross-connection control program before the deadline.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the backflow certificate to the water utility"
        },
        {
          "detail": "Enter the test date, pass/fail, certificate submission date, water heater reading, and any corrective action into the annual test/inspection log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the test date, results, certificate submission, and any corrective action"
        },
        {
          "detail": "Backflow preventer test and water heater check complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Backflow preventer test and water heater check complete"
        },
        {
          "detail": "For a failed backflow assembly, schedule repair or replacement with the certified tester or a licensed plumber and retest before the utility deadline; for an out-of-range water heater, adjust the thermostat and recheck.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule repair or replacement and adjust the water heater as needed"
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Backflow preventer test and water heater temperature check — The annual test date arrives, or the water utility requests a backflow certificate.",
      "title": "Backflow preventer test and water heater temperature check",
      "trigger": "The annual test date arrives, or the water utility requests a backflow certificate",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)",
          "source": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)"
        },
        {
          "kind": "regulation",
          "label": "No specific regulatory authority found for dental-equipment preventive-maintenance intervals — internal manufacturer/manual-driven maintenance schedule — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No specific regulatory authority found for dental-equipment preventive-maintenance intervals — internal manufacturer/manual-driven maintenance schedule — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.157 governs portable fire extinguisher placement/maintenance/testing; 1910.37 governs exit-route design and maintenance; 1910.151 governs first-aid/eyewash provisions for corrosive-exposure workplaces. None of these three sections mention compressors, vacuum filters, dental chairs, sensors, imaging equipment, or furnaces, or set any calibration/service-interval requirement for them.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.157 portable fire extinguishers; 1910.37 exit routes; 1910.151 eyewash",
              "url": null
            }
          },
          "source": "No specific regulatory authority found for dental-equipment preventive-maintenance intervals — internal manufacturer/manual-driven maintenance schedule — Practice policy — no published authority governs this step."
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilizer monitoring and equipment maintenance",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilizer monitoring and equipment maintenance",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "monthly",
      "id": "eqm-009",
      "kind": "operational",
      "materials": [
        "service-log binder or spreadsheet",
        "manufacturer instructions-for-use manuals",
        "manufacturer service-interval schedule",
        "asset tag or serial-number list",
        "calibration reference standard where applicable",
        "work-order or vendor invoice forms"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "sterilization-tech",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Open the equipment log and list every asset (compressor, chairs/delivery units, sterilizers, sensors/imaging equipment, furnace/water heater, backflow device) with its manufacturer service interval and the date it was last serviced.\n\nWhy: A maintenance program only works if every asset is tracked in one place — an asset not on the list is an asset that silently misses its interval.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current asset register",
          "why": "A maintenance program only works if every asset is tracked in one place — an asset not on the list is an asset that silently misses its interval."
        },
        {
          "detail": "Compare today's date against each asset's last-serviced date plus its manufacturer interval; mark any asset due within 30 days or already overdue.\n\nWhy: Manufacturer intervals (e.g. instructions-for-use documents) are the public floor for when servicing is required — missing them can void warranty coverage and, for sterilizers and compressors, create a safety exposure.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag assets due or overdue for service",
          "why": "Manufacturer intervals (e.g. instructions-for-use documents) are the public floor for when servicing is required — missing them can void warranty coverage and, for sterilizers and compressors, create a safety exposure."
        },
        {
          "detail": "Are any assets due or overdue?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — at least one asset needs service"
            },
            {
              "goto": "s11",
              "id": "no",
              "label": "No — all assets current"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are any assets due or overdue?"
        },
        {
          "detail": "For each flagged asset, either book the manufacturer-authorized service vendor or, for tasks the office is authorized to self-perform (filter changes, calibration checks per the manual), assign the sterilization tech or IT vendor and set a date.\n\nWhy: Routing by asset type keeps clinical-safety-critical equipment (sterilizers, compressors feeding handpieces) on qualified service rather than informal fixes.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule service or in-house maintenance for each due asset",
          "why": "Routing by asset type keeps clinical-safety-critical equipment (sterilizers, compressors feeding handpieces) on qualified service rather than informal fixes."
        },
        {
          "detail": "Does the asset touch sterilization, compressed air to handpieces, or patient imaging/sensors?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "clinical",
              "label": "Yes — sterilizer, compressor, imaging sensor or chair delivery unit"
            },
            {
              "goto": "s13",
              "id": "nonclinical",
              "label": "No — facility/IT asset (furnace, water heater, imaging PC hardware)"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the asset touch sterilization, compressed air to handpieces, or patient imaging/sensors?"
        },
        {
          "detail": "Before the vendor visit, the sterilization tech records a baseline function check (e.g. sterilizer spore test result, compressor pressure/output); after service, repeat the check and confirm the reading is within the manufacturer's normal range before returning the asset to clinical use.\n\nWhy: A serviced sterilizer or compressor is not safe to use on the strength of the invoice alone — a function check catches a service that did not actually fix the problem.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Sterilization tech verifies pre- and post-service function",
          "why": "A serviced sterilizer or compressor is not safe to use on the strength of the invoice alone — a function check catches a service that did not actually fix the problem."
        },
        {
          "detail": "Enter asset id, service date, vendor or in-house technician, parts/cost, next-due date, and the function-check result into the service log.\n\nWhy: The log is the evidence a manufacturer, insurer, or inspector will ask for that the interval was actually met.\n\nRecord: Service log entry: asset id, date, performed-by, parts/cost, next-due date, function-check result.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the service in the equipment log",
          "why": "The log is the evidence a manufacturer, insurer, or inspector will ask for that the interval was actually met."
        },
        {
          "detail": "Set the next-due reminder using the manufacturer's interval from the serviced-asset date, not the original schedule date.\n\nWhy: Anchoring the next interval to the actual service date (not the missed target date) keeps the schedule from drifting further out of true over successive cycles.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the next-due date on the maintenance calendar",
          "why": "Anchoring the next interval to the actual service date (not the missed target date) keeps the schedule from drifting further out of true over successive cycles."
        },
        {
          "detail": "Was this service an unplanned breakdown repair rather than routine maintenance?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "planned",
              "label": "Routine, on-schedule maintenance"
            },
            {
              "goto": "s14",
              "id": "breakdown",
              "label": "Unplanned breakdown"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was this service an unplanned breakdown repair rather than routine maintenance?"
        },
        {
          "detail": "All due assets serviced, verified, and logged; next-due dates updated.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Maintenance cycle complete"
        },
        {
          "detail": "Log the check date and 'all assets current' status in the service log.\n\nRecord: Log the check date and 'all assets current' status in the service log.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log that all assets are currently within interval"
        },
        {
          "detail": "All assets current; check logged.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "No service needed this cycle"
        },
        {
          "detail": "For imaging PCs, networked sensors, or facility mechanical equipment, the IT/facility vendor confirms the asset powers on, connects, and passes its normal self-test after service.\n\nWhy: Generic functional-equivalent step: this repo has no vendor-specific IT contract, so verification is described generically as confirming the asset is back in working order before use.",
          "id": "s13",
          "kind": "step",
          "role": "it-vendor",
          "title": "IT/facility vendor confirms asset returned to working order",
          "why": "Generic functional-equivalent step: this repo has no vendor-specific IT contract, so verification is described generically as confirming the asset is back in working order before use."
        },
        {
          "detail": "Note the breakdown date, downtime hours, and repair cost in the equipment record so it feeds the annual replacement-plan protocol (eqm-010).\n\nWhy: Breakdown frequency and rising repair cost are the leading signal that an asset should move up the replacement plan rather than be serviced again.\n\nRecord: Breakdown entry: asset id, date, downtime hours, repair cost.",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the breakdown for the replacement-plan review",
          "why": "Breakdown frequency and rising repair cost are the leading signal that an asset should move up the replacement plan rather than be serviced again."
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Equipment preventive maintenance, calibration and service log (compressors, chairs, sensors, imaging, furnaces) — The manufacturer's service interval elapses or equipment is serviced.",
      "title": "Equipment preventive maintenance, calibration and service log (compressors, chairs, sensors, imaging, furnaces)",
      "trigger": "The manufacturer's service interval elapses or equipment is serviced",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)",
          "source": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)"
        },
        {
          "kind": "generic",
          "label": "Generic fixed-asset depreciation and capital-budgeting practice — no dental-specific public standard; practice-adapted",
          "source": "Generic fixed-asset depreciation and capital-budgeting practice — no dental-specific public standard; practice-adapted"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 120,
      "frequency": "annual",
      "id": "eqm-010",
      "kind": "operational",
      "materials": [
        "asset register with purchase dates and costs",
        "service log history (eqm-009)",
        "current-year budget worksheet",
        "vendor replacement/quote sheets",
        "depreciation schedule or accountant's fixed-asset report"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "List every capital asset: chairs/delivery units, compressors, vacuum system, sterilizers, imaging/sensor hardware, computers/servers, HVAC, water heater, backflow device, furniture. Include purchase date, purchase cost, and current condition.\n\nWhy: The replacement plan is only as complete as the inventory it starts from — a missing asset gets no budget line and fails without warning.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the full equipment inventory",
          "why": "The replacement plan is only as complete as the inventory it starts from — a missing asset gets no budget line and fails without warning."
        },
        {
          "detail": "For each asset, pull the prior year's entries from the equipment service log (eqm-009), including any logged breakdowns, repair costs, and downtime.\n\nWhy: Rising repair frequency or cost is the strongest practical signal that an asset is nearing end of useful life, ahead of any fixed depreciation schedule.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull each asset's service and breakdown history",
          "why": "Rising repair frequency or cost is the strongest practical signal that an asset is nearing end of useful life, ahead of any fixed depreciation schedule."
        },
        {
          "detail": "For each asset, compare its age against a typical useful-life range for its class (e.g. dental chairs and compressors commonly 10-15 years, computers 4-6 years, sterilizers per manufacturer guidance) and note years remaining.\n\nWhy: Useful-life ranges are a generic capital-planning convention adapted for a dental office, not a manufacturer mandate — the practice may override them per asset in its own Method.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Estimate remaining useful life per asset",
          "why": "Useful-life ranges are a generic capital-planning convention adapted for a dental office, not a manufacturer mandate — the practice may override them per asset in its own Method."
        },
        {
          "detail": "Assign a risk level (low/medium/high) per asset combining remaining useful life, breakdown frequency in the past year, and whether a failure would stop patient care (e.g. sole sterilizer, sole compressor) versus be a minor inconvenience.\n\nWhy: Budget is finite; risk scoring prioritizes assets whose failure would actually halt clinical operation over assets that are merely old but redundant or low-impact.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Score each asset's replacement risk",
          "why": "Budget is finite; risk scoring prioritizes assets whose failure would actually halt clinical operation over assets that are merely old but redundant or low-impact."
        },
        {
          "detail": "Rank high-risk assets first and propose a replacement year and estimated cost for each over a 3-5 year horizon, spreading capital spend to avoid multiple major replacements landing in the same year.\n\nWhy: Spreading replacement over years smooths cash flow and avoids a year where several critical assets fail their useful-life window simultaneously.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft the multi-year replacement plan",
          "why": "Spreading replacement over years smooths cash flow and avoids a year where several critical assets fail their useful-life window simultaneously."
        },
        {
          "detail": "For assets proposed for replacement in the next 12 months, request current pricing from qualified vendors to replace the prior year's estimate with an actual quote.\n\nWhy: Equipment pricing moves year to year; an estimate from a prior cycle understates or overstates the real budget need.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect current replacement quotes for near-term items",
          "why": "Equipment pricing moves year to year; an estimate from a prior cycle understates or overstates the real budget need."
        },
        {
          "detail": "The practice owner reviews the ranked replacement plan and proposed budget allocation before it is finalized as this year's capital plan.\n\nWhy: Capital spending is a money decision that belongs to the practice owner, not a step an office manager finalizes alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews and approves the capital plan.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews and approves the capital plan",
          "why": "Capital spending is a money decision that belongs to the practice owner, not a step an office manager finalizes alone."
        },
        {
          "detail": "Does the owner approve the plan as drafted?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "approve",
              "label": "Approve as drafted"
            },
            {
              "goto": "s12",
              "id": "revise",
              "label": "Send back for revision (budget or priority changes)"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the owner approve the plan as drafted?"
        },
        {
          "detail": "Save the approved multi-year replacement plan with the year's budget worksheet and note the approval date and approver.\n\nWhy: A filed, dated plan is what next year's cycle updates rather than rebuilding the inventory from scratch.\n\nRecord: Approved replacement plan: asset list, risk scores, replacement years, quotes, budget, approval date/approver.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Finalize and file the replacement plan",
          "why": "A filed, dated plan is what next year's cycle updates rather than rebuilding the inventory from scratch."
        },
        {
          "detail": "Send the finalized replacement plan and budget figures to whoever manages the practice's books so upcoming purchases are reflected in cash-flow planning and depreciation schedules.\n\nWhy: Finance needs the plan to forecast cash flow and update the depreciation schedule for the newly planned purchases.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the approved plan to finance/bookkeeping",
          "why": "Finance needs the plan to forecast cash flow and update the depreciation schedule for the newly planned purchases."
        },
        {
          "detail": "Plan approved, filed, and handed to finance.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Replacement plan complete for the year"
        },
        {
          "detail": "Adjust rankings, years, or budget figures per the owner's direction and return to the review gate.\n\nWhy: Revision keeps the owner as the final authority on capital allocation rather than the plan shipping unchanged.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Revise the plan per owner feedback",
          "why": "Revision keeps the owner as the final authority on capital allocation rather than the plan shipping unchanged."
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Annual equipment inventory, depreciation and replacement plan — Annually with the budget.",
      "title": "Annual equipment inventory, depreciation and replacement plan",
      "trigger": "Annually with the budget",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — instrument reprocessing and transport of contaminated devices",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — instrument reprocessing and transport of contaminated devices",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule — device and media controls, 45 CFR 164.310(d)",
          "source": "HIPAA Security Rule — device and media controls, 45 CFR 164.310(d)"
        },
        {
          "kind": "regulation",
          "label": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)",
          "source": "FDA reprocessing and manufacturer service intervals for sterilizers, compressors, chairs and sensors (instructions for use)"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "eqm-011",
      "kind": "operational",
      "materials": [
        "decontamination declaration form",
        "shipping packaging per carrier/vendor instructions",
        "data-wipe checklist for imaging PCs/sensors",
        "outbound shipment log",
        "vendor return-merchandise authorization (RMA) if applicable"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What kind of device is being sent out?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "clinical-contact",
              "label": "Handpiece, sensor, or scanner that contacts the patient or oral fluids"
            },
            {
              "goto": "s5",
              "id": "imaging-pc",
              "label": "Imaging PC, server, or storage device (no direct patient contact but may hold data)"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "What kind of device is being sent out?"
        },
        {
          "detail": "Clean and disinfect the device per its instructions-for-use and standard infection-control procedure before it leaves the building; a device that cannot be fully decontaminated must be clearly labeled as biohazard-contaminated for the vendor per shipping instructions.\n\nWhy: A contaminated device shipped without decontamination or labeling is an infection-control and shipping-regulation exposure to the courier and vendor staff who handle it next.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Decontaminate the device before packaging.",
            "role": "assistant",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "assistant",
          "title": "Decontaminate the device before packaging",
          "why": "A contaminated device shipped without decontamination or labeling is an infection-control and shipping-regulation exposure to the courier and vendor staff who handle it next."
        },
        {
          "detail": "Fill out the vendor's or the practice's decontamination declaration: what was cleaned, method used, date, and who performed it. Attach it to the outgoing shipment.\n\nWhy: Most service vendors will not accept or will delay a return without a decontamination declaration attached — this paperwork is what lets the device move.\n\nRecord: Decontamination declaration: device id, method, date, performed-by, attached to shipment.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Complete the decontamination declaration form",
          "why": "Most service vendors will not accept or will delay a return without a decontamination declaration attached — this paperwork is what lets the device move."
        },
        {
          "detail": "Does this device store or cache any patient data (sensor with onboard memory, scanner, imaging unit)?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "yes",
              "label": "Yes — may hold cached patient images or data"
            },
            {
              "goto": "s8",
              "id": "no",
              "label": "No — mechanical device only, no data storage"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does this device store or cache any patient data (sensor with onboard memory, scanner, imaging unit)?"
        },
        {
          "detail": "Before shipment, confirm with the IT vendor or per the device's data-clearing procedure that any cached patient images, records, or credentials are removed or that the device never leaves practice custody (loaner/on-site swap) if a wipe cannot be verified.\n\nWhy: HIPAA's device and media controls require PHI to be removed from equipment before it leaves the practice's control — this is the consequential step the hitl gate exists to catch before the device ships.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm PHI is wiped or the device is otherwise cleared of patient data.",
            "role": "it-vendor",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "it-vendor",
          "title": "Confirm PHI is wiped or the device is otherwise cleared of patient data",
          "why": "HIPAA's device and media controls require PHI to be removed from equipment before it leaves the practice's control — this is the consequential step the hitl gate exists to catch before the device ships."
        },
        {
          "detail": "Was the PHI wipe confirmed successful?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "confirmed",
              "label": "Confirmed — no recoverable patient data remains"
            },
            {
              "goto": "s13",
              "id": "cannot-confirm",
              "label": "Cannot confirm — vendor's wipe tool unavailable or device won't power on"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Was the PHI wipe confirmed successful?"
        },
        {
          "detail": "Log the device id, wipe method, date, and who confirmed it in the outbound shipment log.\n\nWhy: The record is the evidence that the device was cleared before it left the practice's control, should the vendor or a later audit ask.\n\nRecord: PHI-wipe confirmation: device id, method, date, confirmed-by.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Record the PHI-wipe confirmation",
          "why": "The record is the evidence that the device was cleared before it left the practice's control, should the vendor or a later audit ask."
        },
        {
          "detail": "Package per the carrier and vendor's instructions (biohazard labeling if applicable), obtain a tracking number, and enter the shipment in the outbound shipment log with device id, destination, reason (repair or trade-in), and expected return date.\n\nWhy: A logged shipment with a tracking number is how the office notices a device that does not come back on schedule.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Package the device and log the shipment",
          "why": "A logged shipment with a tracking number is how the office notices a device that does not come back on schedule."
        },
        {
          "detail": "Wait for the vendor's expected turnaround window (per the RMA or service ticket) and check the shipment log weekly until the device is received back or the trade-in credit is confirmed.\n\nWhy: Waiting for the return prevents a shipped device from being quietly forgotten and never followed up on.",
          "id": "s9",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1200,
          "title": "Track the device until it returns or the trade-in completes",
          "why": "Waiting for the return prevents a shipped device from being quietly forgotten and never followed up on."
        },
        {
          "detail": "Did the device return or the trade-in complete on schedule?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "returned",
              "label": "Yes — device received back or trade-in credit confirmed"
            },
            {
              "goto": "s14",
              "id": "overdue",
              "label": "No — past the expected return date"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the device return or the trade-in complete on schedule?"
        },
        {
          "detail": "Mark the shipment log entry complete with the return date or trade-in confirmation, and if the returned device is a clinical-contact item, route it through standard reprocessing before returning it to clinical use.\n\nWhy: A device returning from an outside service center is treated as new-to-the-practice for infection-control purposes until it is reprocessed per normal protocol.\n\nRecord: Shipment log closed: device id, return/trade-in date, reprocessing-before-use noted if applicable.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Close out the shipment log entry",
          "why": "A device returning from an outside service center is treated as new-to-the-practice for infection-control purposes until it is reprocessed per normal protocol."
        },
        {
          "detail": "Device decontaminated/PHI-cleared, logged, and its return or trade-in resolved.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Equipment shipment cycle closed"
        },
        {
          "detail": "Do not ship a device whose data state cannot be confirmed wiped. Options: request a loaner swap where the original stays on-site, physically remove and retain the storage media before shipping the rest, or escalate to the office manager for a vendor-specific data-destruction agreement.\n\nWhy: Shipping an unclearable device with cached PHI outside the practice's control is the exposure this whole protocol exists to prevent — the safer failure mode is to not ship rather than to ship uncertain.",
          "id": "s13",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hold the shipment and pursue an alternative to sending the device with unclearable data",
          "why": "Shipping an unclearable device with cached PHI outside the practice's control is the exposure this whole protocol exists to prevent — the safer failure mode is to not ship rather than to ship uncertain."
        },
        {
          "detail": "Contact the vendor using the tracking number and service ticket to get a status update and revised return date; update the shipment log with the new expected date.\n\nWhy: An overdue clinical device (handpiece, sensor) may need to be replaced or borrowed to avoid a gap in patient care if it doesn't come back promptly.",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Follow up with the vendor on the overdue shipment",
          "why": "An overdue clinical device (handpiece, sensor) may need to be replaced or borrowed to avoid a gap in patient care if it doesn't come back promptly."
        }
      ],
      "subclass": "equipment-and-facility-maintenance",
      "summary": "Equipment sent out for repair or trade-in: decontamination declaration and PHI wipe — A handpiece, sensor, scanner or imaging PC is shipped to a service center.",
      "title": "Equipment sent out for repair or trade-in: decontamination declaration and PHI wipe",
      "trigger": "A handpiece, sensor, scanner or imaging PC is shipped to a service center",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State criminal statutes governing employee theft/embezzlement (varies by state; e.g. California Penal Code §503 defines embezzlement by an employee, agent, or other person entrusted with property)",
          "source": "State criminal statutes governing employee theft/embezzlement (varies by state; e.g. California Penal Code §503 defines embezzlement by an employee, agent, or other person entrusted with property)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=503"
        },
        {
          "kind": "generic",
          "label": "Standard employee-theft/embezzlement response practice — evidence preservation, access freeze, fidelity-bond/crime-insurance claim process, and law-enforcement reporting; no single public-domain document governs internal financial-controls response, this is generic functional equivalence to commercial fidelity-bond and internal-audit practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard employee-theft/embezzlement response practice — evidence preservation, access freeze, fidelity-bond/crime-insurance claim process, and law-enforcement reporting; no single public-domain document governs internal financial-controls response, this is generic functional equivalence to commercial fidelity-bond and internal-audit practice"
          },
          "source": "Standard employee-theft/embezzlement response practice — evidence preservation, access freeze, fidelity-bond/crime-insurance claim process, and law-enforcement reporting; no single public-domain document governs internal financial-controls response, this is generic functional equivalence to commercial fidelity-bond and internal-audit practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "fin-001",
      "kind": "operational",
      "materials": [
        "financial system read-only export",
        "bank statements",
        "day sheets",
        "adjustment log",
        "incident log template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "billing",
        "hr",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Note the date, time, and specific evidence that triggered suspicion; do not accuse or discuss with the suspected employee or coworkers.\n\nWhy: Premature confrontation lets evidence disappear and can trigger destruction of records or flight.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Do not confront the employee yet",
          "why": "Premature confrontation lets evidence disappear and can trigger destruction of records or flight."
        },
        {
          "detail": "Revoke the employee's login to the practice management, banking, and credit-card systems immediately, without explanation to the employee.\n\nWhy: Access must be cut before the person under suspicion can alter records.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Freeze the suspect's system and financial access",
          "why": "Access must be cut before the person under suspicion can alter records."
        },
        {
          "detail": "Contact practice attorney and (if applicable) compliance officer before deciding on termination, law-enforcement report, or bonding claim.\n\nWhy: Wrongful-termination and defamation exposure make legal review mandatory before acting.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Loop in counsel and compliance before any action plan is finalized.",
            "role": "practice-owner with legal counsel",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Loop in counsel and compliance before any action plan is finalized",
          "why": "Wrongful-termination and defamation exposure make legal review mandatory before acting."
        },
        {
          "detail": "Export financial records read-only, print or PDF day sheets and bank statements, and store copies off the practice's own system in case access is later needed for the suspect's role.\n\nWhy: Altered or missing records undermine both an insurance claim and a criminal case.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Preserve evidence in its original form",
          "why": "Altered or missing records undermine both an insurance claim and a criminal case."
        },
        {
          "detail": "Reconcile bank deposits against day-sheet totals and adjustment logs for the full suspected period, using a person not implicated in the discrepancy.\n\nWhy: An accurate dollar figure is required for the police report, bonding claim, and any civil recovery.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Quantify the loss with an independent reconciliation",
          "why": "An accurate dollar figure is required for the police report, bonding claim, and any civil recovery."
        },
        {
          "detail": "Weigh evidence strength, counsel's advice, and payroll/HR rules for the jurisdiction.\n\nWhy: Timing errors here create wrongful-termination risk.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "leave",
              "label": "Place on administrative leave pending investigation (advised)"
            },
            {
              "goto": "s7",
              "id": "terminate",
              "label": "Terminate immediately with counsel sign-off"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to place the employee on leave or terminate",
          "why": "Timing errors here create wrongful-termination risk."
        },
        {
          "detail": "Report the theft to local law enforcement with the reconciliation package and preserved records as supporting evidence.\n\nWhy: A police report is typically required to file a fidelity-bond or crime-insurance claim.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "File a police report",
          "why": "A police report is typically required to file a fidelity-bond or crime-insurance claim."
        },
        {
          "detail": "Open a claim with the practice's fidelity bond or employee-dishonesty insurance rider, if one exists, within the policy's notice window.\n\nWhy: Missing the carrier's notice deadline can void recovery.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the bonding or crime-insurance carrier",
          "why": "Missing the carrier's notice deadline can void recovery."
        },
        {
          "detail": "Add or restore dual sign-off on refunds and adjustments, separate the cash-handling and reconciliation roles, and enable audit-trail alerts in the financial system.\n\nWhy: The gap that allowed diversion (usually single-person control over money) must close before restaffing the role.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Tighten controls to prevent recurrence",
          "why": "The gap that allowed diversion (usually single-person control over money) must close before restaffing the role."
        },
        {
          "detail": "Record discovery date, freeze date, reconciliation total, report filing, and control changes in the incident log.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the full incident timeline"
        },
        {
          "detail": "Incident closed and controls updated",
          "id": "s11",
          "kind": "step",
          "title": "Incident closed and controls updated"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Embezzlement or employee theft discovered — freeze, evidence, reporting — Reconciliation, a bank alert, a tip or adjustment patterns reveal systematic diversion of practice funds by a specific employee.",
      "title": "Embezzlement or employee theft discovered — freeze, evidence, reporting",
      "trigger": "Reconciliation, a bank alert, a tip or adjustment patterns reveal systematic diversion of practice funds by a specific employee",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Standard end-of-day cash-drawer and card-batch reconciliation practice (independent re-count, batch-to-ledger matching, dual sign-off on the corrected total) — generic internal-control functional equivalent, no single public-domain document governs day-to-day cash reconciliation — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard end-of-day cash-drawer and card-batch reconciliation practice (independent re-count, batch-to-ledger matching, dual sign-off on the corrected total) — generic internal-control functional equivalent, no single public-domain document governs day-to-day cash reconciliation"
          },
          "source": "Standard end-of-day cash-drawer and card-batch reconciliation practice (independent re-count, batch-to-ledger matching, dual sign-off on the corrected total) — generic internal-control functional equivalent, no single public-domain document governs day-to-day cash reconciliation — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "— daily cash reconciliation, no applicable regulatory authority — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic functional equivalent — daily cash reconciliation, no applicable regulatory authority"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Covered accounts are any accounts that ... involve a reasonably foreseeable risk from identity theft ... Examples of identity theft indicators [include] a fraud or active duty alert ... a notice of credit freeze ... a notice of address discrepancy.",
            "ticket": "PROT-017",
            "was": {
              "source": "FTC Red Flags Rule 16 CFR Part 681 (customer-facing financial identification and record-integrity program)",
              "url": "https://www.ecfr.gov/current/title-16/part-681"
            }
          },
          "source": "— daily cash reconciliation, no applicable regulatory authority — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "fin-002",
      "kind": "operational",
      "materials": [
        "day sheet",
        "cash drawer count sheet",
        "card terminal batch report",
        "deposit slip"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "A second staff member re-counts bills and coins separately from the person who closed out, without seeing the first count.\n\nWhy: A second independent count rules out a simple counting error before treating it as a real discrepancy.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Re-count the cash drawer independently",
          "why": "A second independent count rules out a simple counting error before treating it as a real discrepancy."
        },
        {
          "detail": "Print or pull the terminal's batch total and match it line by line against card payments logged on the day sheet.\n\nWhy: Card discrepancies usually trace to a duplicate charge, a declined transaction still logged, or a wrong amount keyed.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Compare the card terminal batch to the day sheet",
          "why": "Card discrepancies usually trace to a duplicate charge, a declined transaction still logged, or a wrong amount keyed."
        },
        {
          "detail": "Decide whether the source is now identified.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "resolved",
              "label": "Source found and corrected (advised)"
            },
            {
              "goto": "s7",
              "id": "unresolved",
              "label": "Still unexplained"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the discrepancy resolved by the re-count and batch check?"
        },
        {
          "detail": "Note what caused the discrepancy and the corrected total, with the initials of both staff who verified it.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the correction on the day sheet"
        },
        {
          "detail": "Prepare the deposit slip matching the verified or documented total and route it per the deposit-transport protocol.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete the bank deposit"
        },
        {
          "detail": "Day closed and reconciled",
          "id": "s6",
          "kind": "step",
          "title": "Day closed and reconciled"
        },
        {
          "detail": "Pull printed or system receipts for every cash and check transaction of the day and match each to a patient ledger entry.\n\nWhy: Line-by-line matching finds a missed entry or a transposed amount that a total-level check misses.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Review individual transaction receipts",
          "why": "Line-by-line matching finds a missed entry or a transposed amount that a total-level check misses."
        },
        {
          "detail": "If the gap is still unexplained above the practice's escalation threshold, treat it as a control concern rather than a clerical one.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "found",
              "label": "Source found on transaction review (advised)"
            },
            {
              "goto": "s9",
              "id": "escalate",
              "label": "Escalate as an unresolved shortage"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the discrepancy still unresolved after transaction review?"
        },
        {
          "detail": "Report the unresolved amount, the staff involved in the day's cash handling, and the steps already taken to the practice owner.\n\nWhy: A repeated or large unresolved shortage may indicate a control gap or theft and needs owner-level judgment (see fin-001 if theft is suspected).",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the practice owner",
          "why": "A repeated or large unresolved shortage may indicate a control gap or theft and needs owner-level judgment (see fin-001 if theft is suspected)."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "End-of-day cash drawer or deposit does not balance — The day-sheet total, card batch, cash count and deposit slip disagree.",
      "title": "End-of-day cash drawer or deposit does not balance",
      "trigger": "The day-sheet total, card batch, cash count and deposit slip disagree",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Health & Safety Code §1371.1 — health-plan overpayment-notice/refund-dispute timing only",
          "repaired": {
            "action": "reduce",
            "evidence": "The audit's own verification (via search) confirms H&S §1371.1 governs health-plan-to-provider overpayment notice, 30-day response, and interest-accrual rules — matching fin-017's subject exactly. The bundled URL (sco.ca.gov/upd_rptg.html) is the State Controller's Unclaimed Property reporting page and addresses escheatment, not any of the three protocols' subjects.",
            "ticket": "PROT-017",
            "was": {
              "source": "California overpayment recoupment limits H&S §1371.1 / Ins. Code §10123.145; Unclaimed Property Law CCP §1500 et seq.; Rosenthal Act Civ. Code §1788",
              "url": "https://www.sco.ca.gov/upd_rptg.html"
            }
          },
          "source": "Cal. Health & Safety Code §1371.1 (health-plan-to-provider overpayment notice, statutory time limits, interest accrual). Scope: fin-017 (payer overpayment notice — verification, statutory time limits, refund or dispute) only — does NOT reach fin-003 (patient demands a refund for treatment/prepayment) or fin-025 (patient bankruptcy notice), which are not overpayment-recoupment matters. Drops the Unclaimed Property Law citation and its URL (sco.ca.gov/upd_rptg.html is the State Controller's unclaimed-property page and supports none of the three protocols) and drops the Rosenthal Fair Debt Collection Act (Civ. Code §1788, which governs debt-collection conduct, not refund/overpayment mechanics).",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1371.1&lawCode=HSC"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fin-003",
      "kind": "operational",
      "materials": [
        "patient ledger",
        "treatment record",
        "refund request form",
        "practice financial policy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "dentist",
        "office-manager",
        "practice-owner",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Record the patient's stated reason, date of request, and amount claimed on the refund request form.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the refund request"
        },
        {
          "detail": "Verify the actual account balance, what was paid, what was billed to insurance, and what treatment (if any) was delivered.\n\nWhy: The stated request amount and the actual ledger balance frequently differ.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Pull the ledger and treatment record",
          "why": "The stated request amount and the actual ledger balance frequently differ."
        },
        {
          "detail": "Compare the ledger to the patient's claim: overpayment, cancelled treatment prepayment, insurance overpayment already refunded to the payer, or dissatisfaction with completed treatment.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "valid",
              "label": "Confirmed credit balance or valid basis (advised)"
            },
            {
              "goto": "s8",
              "id": "disputed",
              "label": "No credit balance found, or basis is disputed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Is there a genuine credit balance or valid refund basis?"
        },
        {
          "detail": "Refunds above the practice's set dollar threshold require office-manager or owner approval before processing.\n\nWhy: A financial-control gate prevents an unauthorized or erroneous large refund from processing unreviewed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Get owner or office manager sign-off above the approval threshold.",
            "role": "office-manager or practice-owner",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "office-manager",
          "title": "Get owner or office manager sign-off above the approval threshold",
          "why": "A financial-control gate prevents an unauthorized or erroneous large refund from processing unreviewed."
        },
        {
          "detail": "Issue the refund by the same method as original payment where possible (card reversal, check, or account credit), and note the transaction id in the ledger.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Process the refund"
        },
        {
          "detail": "Record the outcome, amount (if any), method, and date in the patient ledger and the refund log.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Document the final resolution"
        },
        {
          "detail": "Refund request resolved",
          "id": "s7",
          "kind": "step",
          "title": "Refund request resolved"
        },
        {
          "detail": "Send a written summary showing the account balance and why no refund (or a different amount) is owed, referencing the practice's written financial policy.\n\nWhy: A written explanation protects both parties if the dispute continues to a chargeback or complaint.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Explain the ledger finding to the patient in writing",
          "why": "A written explanation protects both parties if the dispute continues to a chargeback or complaint."
        },
        {
          "detail": "Patient may accept the explanation or push back further (complaint, review, chargeback, small-claims threat).",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "resolved",
              "label": "Patient accepts the explanation (advised)"
            },
            {
              "goto": "s10",
              "id": "escalated",
              "label": "Patient escalates further"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the patient escalate the dispute?"
        },
        {
          "detail": "Hand the full file (ledger, treatment record, correspondence) to the practice owner for a final decision, including possible goodwill exception or referral to legal counsel.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Route to the practice owner for final resolution"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Patient demands a refund for treatment or a prepayment — A patient asks for money back citing dissatisfaction, cancelled treatment or a credit balance.",
      "title": "Patient demands a refund for treatment or a prepayment",
      "trigger": "A patient asks for money back citing dissatisfaction, cancelled treatment or a credit balance",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "The payer's own network participation agreement — its termination-notice period, termination-without-cause clause, and fee-schedule-amendment clause govern this scenario; no public-domain document covers a private commercial contract's specific terms — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "The payer's own network participation agreement — its termination-notice period, termination-without-cause clause, and fee-schedule-amendment clause govern this scenario; no public-domain document covers a private commercial contract's specific terms"
          },
          "source": "The payer's own network participation agreement — its termination-notice period, termination-without-cause clause, and fee-schedule-amendment clause govern this scenario; no public-domain document covers a private commercial contract's specific terms — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "State insurance-department provider-network-termination notice and continuity-of-care practices (varies by state and payer type; verify against the specific state's insurance code and, for a Knox-Keene-licensed health plan operating in California, the plan's DMHC filing requirements)",
          "source": "State insurance-department provider-network-termination notice and continuity-of-care practices (varies by state and payer type; verify against the specific state's insurance code and, for a Knox-Keene-licensed health plan operating in California, the plan's DMHC filing requirements)"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "fin-004",
      "kind": "operational",
      "materials": [
        "payer participation agreement",
        "current fee schedule",
        "active-patient-by-plan report",
        "patient notification letter template"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "insurance-coordinator",
        "billing",
        "office-manager",
        "front-desk",
        "treatment-coordinator",
        "marketing",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Read the new fee schedule or termination notice against the contract's notice-period and termination-without-cause clauses.\n\nWhy: Contract terms set the legal notice window and any obligations owed to patients mid-treatment.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the payer's notice and the participation agreement",
          "why": "Contract terms set the legal notice window and any obligations owed to patients mid-treatment."
        },
        {
          "detail": "Pull the active-patient-by-plan report and calculate revenue impact of accepting the new fees versus dropping the plan.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Model the financial impact"
        },
        {
          "detail": "Weigh revenue impact, patient volume on the plan, and administrative burden.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "accept",
              "label": "Accept and continue participating (advised default absent a strong reason to exit)"
            },
            {
              "goto": "s6",
              "id": "negotiate",
              "label": "Request a rate negotiation before deciding"
            },
            {
              "goto": "s7",
              "id": "exit",
              "label": "Exit the network"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Accept the new terms, negotiate, or exit the network"
        },
        {
          "detail": "Load the new allowed amounts and confirm they apply going forward for the correct effective date.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Update the fee schedule in the billing system"
        },
        {
          "detail": "Payer relationship change complete",
          "id": "s5",
          "kind": "step",
          "title": "Payer relationship change complete"
        },
        {
          "detail": "Send a written request citing local fee benchmarks and practice volume, with a response deadline before the notice period expires.\n\nWhy: A negotiation request must not be allowed to run past the contractual decision deadline.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Submit a rate negotiation request to the payer",
          "why": "A negotiation request must not be allowed to run past the contractual decision deadline."
        },
        {
          "detail": "Submit written termination per the contract's required method and notice period, keeping proof of delivery.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Send the network-exit or termination notice to the payer"
        },
        {
          "detail": "Pull the active-patient-by-plan report and flag anyone with treatment in progress who may need continuity-of-care handling under the contract.\n\nWhy: Some payer contracts require continued in-network treatment of patients mid-course of care through a transition period.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Identify patients mid-treatment on the exiting plan",
          "why": "Some payer contracts require continued in-network treatment of patients mid-course of care through a transition period."
        },
        {
          "detail": "Share the exit effective date and updated patient-responsibility estimates so scheduling and treatment presentations reflect the change going forward.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify front desk and treatment coordinator of the effective date"
        },
        {
          "detail": "Mail or email affected patients before the effective date, explaining the change, their new estimated cost, and alternative-plan or self-pay options.\n\nWhy: Advance notice avoids surprise billing disputes and preserves patient trust.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Send patient notification letters",
          "why": "Advance notice avoids surprise billing disputes and preserves patient trust."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Payer fee-schedule cut, contract termination or network exit — decision, notice period and patient notification — A payer notifies new allowed fees effective on a stated date or sends a termination notice, or the owner decides to drop a plan.",
      "title": "Payer fee-schedule cut, contract termination or network exit — decision, notice period and patient notification",
      "trigger": "A payer notifies new allowed fees effective on a stated date or sends a termination notice, or the owner decides to drop a plan",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Standard 13-week cash-flow-projection and short-term liquidity-management practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard 13-week cash-flow-projection and short-term liquidity-management practice — generic functional equivalent to small-business cash management guidance, no single public-domain document governs a practice's own cash forecast"
          },
          "source": "Standard 13-week cash-flow-projection and short-term liquidity-management practice — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Standard accounts-receivable aging and collections practice (prioritizing oldest/largest balances, payment-plan offers) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard accounts-receivable aging and collections practice (prioritizing oldest/largest balances, payment-plan offers) — generic functional equivalent, not governed by a specific public-domain document"
          },
          "source": "Standard accounts-receivable aging and collections practice (prioritizing oldest/largest balances, payment-plan offers) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "fin-005",
      "kind": "operational",
      "materials": [
        "13-week cash flow projection",
        "accounts-receivable aging report",
        "line-of-credit terms",
        "expense ledger"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "List all confirmed cash in (collections, insurance payments due) and cash out (payroll, rent, loan payments, supplies) week by week for the next 13 weeks.\n\nWhy: A precise weekly picture, not a monthly guess, is needed to know exactly which payment is at risk and when.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Build a 13-week cash flow projection",
          "why": "A precise weekly picture, not a monthly guess, is needed to know exactly which payment is at risk and when."
        },
        {
          "detail": "Confirm the gap against the projection before taking action.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "confirmed",
              "label": "Shortfall confirmed (advised)"
            },
            {
              "goto": "s7",
              "id": "false-alarm",
              "label": "Projection resolves itself — no action needed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is the shortfall confirmed within 30 days?"
        },
        {
          "detail": "Pull the accounts-receivable aging report, prioritize the largest and oldest balances, and push same-week collection calls and payment-plan offers.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Accelerate collections"
        },
        {
          "detail": "Pause non-essential purchases, marketing spend, and optional CE or supply orders until the gap closes.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Cut discretionary spend for the period"
        },
        {
          "detail": "Re-check the 13-week projection after steps n3 and n4.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "closed",
              "label": "Gap closed (advised)"
            },
            {
              "goto": "s8",
              "id": "still-short",
              "label": "Still short"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the gap still remain after collections and cuts?"
        },
        {
          "detail": "Log the projected gap, actions taken, and outcome for the financial file, and update the 13-week projection going forward.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the crunch and the response taken"
        },
        {
          "detail": "Immediate cash risk addressed",
          "id": "s7",
          "kind": "step",
          "title": "Immediate cash risk addressed"
        },
        {
          "detail": "Use the practice's pre-existing line of credit or cash reserve rather than a new emergency loan, if one is available.\n\nWhy: An existing facility is faster and cheaper than arranging new financing under time pressure.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Draw on an existing line of credit or reserve",
          "why": "An existing facility is faster and cheaper than arranging new financing under time pressure."
        },
        {
          "detail": "If funds remain insufficient for everything, pay payroll first and communicate proactively with the landlord or lender about the other payment.\n\nWhy: Wage-and-hour law makes payroll the least negotiable obligation; landlords and lenders can be given advance notice, which unpaid employees cannot.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Prioritize payroll over other obligations if the gap is still not fully closed",
          "why": "Wage-and-hour law makes payroll the least negotiable obligation; landlords and lenders can be given advance notice, which unpaid employees cannot."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Cash crunch — payroll or rent at risk within 30 days — Projected cash cannot cover the next payroll, rent or loan payment.",
      "title": "Cash crunch — payroll or rent at risk within 30 days",
      "trigger": "Projected cash cannot cover the next payroll, rent or loan payment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Uniform Commercial Code Article 9 (secured transactions) — the default, cure and workout framework most commercial lending agreements are drafted against, as adopted state-by-state",
          "source": "Uniform Commercial Code Article 9 (secured transactions) — the default, cure and workout framework most commercial lending agreements are drafted against, as adopted state-by-state",
          "url": "https://www.law.cornell.edu/ucc/9"
        },
        {
          "kind": "generic",
          "label": "Standard commercial-lending covenant-cure and workout practice (written response to notice, engaging an accountant/advisor, cure plan or waiver request) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard commercial-lending covenant-cure and workout practice (written response to notice, engaging an accountant/advisor, cure plan or waiver request) — generic functional equivalent, no single public-domain document governs a specific bank's loan agreement"
          },
          "source": "Standard commercial-lending covenant-cure and workout practice (written response to notice, engaging an accountant/advisor, cure plan or waiver request) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "fin-006",
      "kind": "operational",
      "materials": [
        "loan agreement",
        "lender notice letter",
        "current financial statements",
        "13-week cash flow projection"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Identify exactly which covenant or payment term was breached and what cure period, if any, the agreement provides.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Read the notice against the loan agreement's covenant terms"
        },
        {
          "detail": "Acknowledge receipt of the lender's notice in writing within the deadline the notice specifies, even if the full response is still being prepared.\n\nWhy: Silence past a stated deadline can itself be treated as a further default under many loan agreements.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Do not ignore or let the notice go unanswered",
          "why": "Silence past a stated deadline can itself be treated as a further default under many loan agreements."
        },
        {
          "detail": "Bring in the practice's accountant or a financial advisor experienced with lender workouts before responding substantively.\n\nWhy: Covenant negotiations and cure plans typically require financial-statement work beyond day-to-day bookkeeping.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage an accountant or financial advisor",
          "why": "Covenant negotiations and cure plans typically require financial-statement work beyond day-to-day bookkeeping."
        },
        {
          "detail": "Draft a written plan showing how and when the covenant will be met again, or request a temporary waiver with supporting current financials.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare a cure plan or waiver request"
        },
        {
          "detail": "Await the lender's written response.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "accepted",
              "label": "Lender accepts cure plan or waiver (advised)"
            },
            {
              "goto": "s8",
              "id": "rejected",
              "label": "Lender rejects or escalates toward default"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the lender accept the cure plan or grant a waiver?"
        },
        {
          "detail": "File the lender's written acceptance and calendar the required reporting or payment dates going forward.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the agreed cure plan and set follow-up reminders"
        },
        {
          "detail": "Lender matter resolved or handed to counsel",
          "id": "s7",
          "kind": "step",
          "title": "Lender matter resolved or handed to counsel"
        },
        {
          "detail": "Route the file to an attorney experienced in commercial lending workouts before any further lender communication.\n\nWhy: A rejected cure plan raises real acceleration and legal risk that needs counsel, not just accounting, involvement.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage legal counsel for default or workout negotiation",
          "why": "A rejected cure plan raises real acceleration and legal risk that needs counsel, not just accounting, involvement."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Loan covenant breach or lender default notice — The lender flags a missed payment, financial-reporting failure or covenant breach.",
      "title": "Loan covenant breach or lender default notice",
      "trigger": "The lender flags a missed payment, financial-reporting failure or covenant breach",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "IRS Publication 556, Examination of Returns, Appeal Rights, and Claims for Refund — governs IRS notice, audit-selection and appeal procedure",
          "source": "IRS Publication 556, Examination of Returns, Appeal Rights, and Claims for Refund — governs IRS notice, audit-selection and appeal procedure",
          "url": "https://www.irs.gov/publications/p556"
        },
        {
          "kind": "statute",
          "label": "IRS Form 8300 cash reporting 26 U.S.C. §6050I (referenced when a tax notice concerns large-cash reporting)",
          "source": "IRS Form 8300 cash reporting 26 U.S.C. §6050I (referenced when a tax notice concerns large-cash reporting)",
          "url": "https://www.irs.gov/businesses/small-businesses-self-employed/form-8300-and-reporting-cash-payments-of-over-10000"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "fin-007",
      "kind": "operational",
      "materials": [
        "tax notice letter",
        "prior year tax returns",
        "supporting financial records",
        "IRS Publication 556 reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Identify the tax year, the specific issue (deficiency, penalty, lien, or audit selection), and the exact date a response is due.\n\nWhy: Tax notices carry hard statutory deadlines; missing one forfeits appeal rights that exist only within the window.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Read the notice completely and note the response deadline",
          "why": "Tax notices carry hard statutory deadlines; missing one forfeits appeal rights that exist only within the window."
        },
        {
          "detail": "Even a notice that looks incorrect must be responded to in writing by the deadline; silence is treated as agreement in many cases.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Do not ignore the notice or assume it is an error"
        },
        {
          "detail": "Gather the filed return for the year in question along with the underlying financial records that support the reported figures.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the relevant tax return and supporting records"
        },
        {
          "detail": "Route the notice and supporting records to the practice's CPA (routine notices) or a tax attorney (liens, audits, or fraud allegations) before responding.\n\nWhy: A response drafted without professional review can concede issues that a qualified response would have contested.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage the practice's accountant or a tax attorney",
          "why": "A response drafted without professional review can concede issues that a qualified response would have contested."
        },
        {
          "detail": "Submit the response, payment plan request, or appeal through the method the notice specifies, keeping proof of timely filing.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "File the response by the deadline"
        },
        {
          "detail": "Track the agency's reply.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "closed",
              "label": "Matter resolved or accepted (advised)"
            },
            {
              "goto": "s9",
              "id": "escalated",
              "label": "Escalates to formal audit, lien enforcement, or appeal"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the agency accept the response, or is it escalated?"
        },
        {
          "detail": "Store the agency's closing letter or acceptance with the tax records for that year.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "File the resolution documentation"
        },
        {
          "detail": "Tax matter resolved",
          "id": "s8",
          "kind": "step",
          "title": "Tax matter resolved"
        },
        {
          "detail": "Follow the accountant's or attorney's guidance through the audit, appeal, or lien-release process, keeping every document filed.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Continue with counsel through the formal process"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "IRS or state tax notice, lien or audit letter — A tax agency sends a notice of deficiency, penalty, lien or audit selection.",
      "title": "IRS or state tax notice, lien or audit letter",
      "trigger": "A tax agency sends a notice of deficiency, penalty, lien or audit selection",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Standard payroll-processing failure-response practice (root-cause triage, emergency manual pay fallback, proactive staff notice) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard payroll-processing failure-response practice (root-cause triage, emergency manual pay fallback, proactive staff notice) — generic functional equivalent, no single public-domain document governs payroll-processor incident response"
          },
          "source": "Standard payroll-processing failure-response practice (root-cause triage, emergency manual pay fallback, proactive staff notice) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 (record-integrity controls referenced for payroll-account safeguards)",
          "source": "FTC Red Flags Rule 16 CFR Part 681 (record-integrity controls referenced for payroll-account safeguards)",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "fin-008",
      "kind": "operational",
      "materials": [
        "payroll processor error message",
        "bank account balance",
        "employee contact list",
        "state wage-payment rules reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Check whether the failure is a processor system error, insufficient funds in the funding account, or a submission error (wrong file, missed cutoff, incorrect account details).",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the root cause immediately"
        },
        {
          "detail": "Confirm the bank balance against the payroll amount due.",
          "forks": [
            {
              "goto": "s8",
              "id": "funds-short",
              "label": "Account is short of funds"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "processing-error",
              "label": "Processing or submission error, funds available (advised)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is the account short of funds, or is it a processing error?"
        },
        {
          "detail": "Call the processor directly (not just email) to get the fastest path to re-running the payroll or expediting the ACH.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Contact the payroll processor's support line"
        },
        {
          "detail": "Get a firm timeline from the processor.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "on-time",
              "label": "Processor can re-run in time (advised)"
            },
            {
              "goto": "s9",
              "id": "delayed",
              "label": "Wages will be delayed beyond payday"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Can the processor re-run in time for wages to land on or near payday?"
        },
        {
          "detail": "Log the cause, the fix, the date wages actually landed, and any penalty or make-up amount paid to employees.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the failure and resolution"
        },
        {
          "detail": "Set an earlier internal payroll-submission deadline, add a funding-balance check two days before each run, or add a backup processor contact.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Add a safeguard against recurrence"
        },
        {
          "detail": "Payroll failure resolved",
          "id": "s7",
          "kind": "step",
          "title": "Payroll failure resolved"
        },
        {
          "detail": "Transfer from reserves, draw a line of credit, or move funds from another account to cover the shortfall before re-running or manually paying.\n\nWhy: Wage-and-hour law makes on-time payroll a legal obligation, not a discretionary payment (see fin-005 if this reflects a broader cash crunch).",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Move funds to cover payroll immediately",
          "why": "Wage-and-hour law makes on-time payroll a legal obligation, not a discretionary payment (see fin-005 if this reflects a broader cash crunch)."
        },
        {
          "detail": "Issue same-day checks or a direct bank transfer to employees for the amount owed while the processor issue is resolved.\n\nWhy: Late wages carry statutory penalties in many states; a manual fallback limits the delay even if it is administratively heavier.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Pay manually as an emergency fallback",
          "why": "Late wages carry statutory penalties in many states; a manual fallback limits the delay even if it is administratively heavier."
        },
        {
          "detail": "Tell staff before payday, or as soon as the delay is known, what happened and exactly when they will be paid.\n\nWhy: Proactive notice preserves trust and reduces the chance of a wage complaint being filed before the fix lands.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Notify affected employees proactively",
          "why": "Proactive notice preserves trust and reduces the chance of a wage complaint being filed before the fix lands."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Payroll run fails or wages will be late — The payroll processor rejects the run, the account is short, or direct deposits do not land on payday.",
      "title": "Payroll run fails or wages will be late",
      "trigger": "The payroll processor rejects the run, the account is short, or direct deposits do not land on payday",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "No authority located covers counterfeit-currency/bounced-check/stolen-card front-desk response; treat as a standard payment-handling and loss-mitigation control — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No authority located covers counterfeit-currency/bounced-check/stolen-card front-desk response; treat as a standard payment-handling and loss-mitigation control — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "IRS Publication 556 is 'Examination of Returns, Appeal Rights, and Claims for Refund' — it covers IRS audit/appeal procedure, not payment acceptance or counterfeit/fraud detection at point of sale.",
            "ticket": "PROT-017",
            "was": {
              "source": "IRS Publication 556 / generic cash-handling and reconciliation controls",
              "url": null
            }
          },
          "source": "No authority located covers counterfeit-currency/bounced-check/stolen-card front-desk response; treat as a standard payment-handling and loss-mitigation control — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "No applicable authority — counterfeit-bill/bad-check/stolen-card handling is an internal desk procedure and card-network fraud-liability matter, not a PCI DSS control — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No applicable authority — counterfeit-bill/bad-check/stolen-card handling is an internal desk procedure and card-network fraud-liability matter, not a PCI DSS control — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "\"The PCI Security Standards Council (PCI SSC) is a global forum that brings together payments industry stakeholders to develop and drive adoption of data security standards and resources for safe payments worldwide.\" — describes PCI DSS's scope as payment-card data security, with no fraud-detection-at-point-of-sale procedural content.",
            "ticket": "PROT-017",
            "was": {
              "source": "PCI DSS (open standard) card-acceptance controls",
              "url": "https://www.pcisecuritystandards.org/"
            }
          },
          "source": "No applicable authority — counterfeit-bill/bad-check/stolen-card handling is an internal desk procedure and card-network fraud-liability matter, not a PCI DSS control — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fin-009",
      "kind": "operational",
      "materials": [
        "counterfeit-detector pen or UV light",
        "bank returned-item notice",
        "card processor dispute portal login",
        "patient account ledger"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note which payment failed: counterfeit currency caught at drop, a bounced/NSF check notice from the bank, or a card processor stolen-card chargeback alert.\n\nWhy: Each path has a different next step and a different recovery mechanism.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the flagged item",
          "why": "Each path has a different next step and a different recovery mechanism."
        },
        {
          "detail": "Route by payment type",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-cash",
              "label": "Counterfeit currency"
            },
            {
              "goto": "s11",
              "id": "opt-check",
              "label": "Bounced check"
            },
            {
              "goto": "s12",
              "id": "opt-card",
              "label": "Stolen-card chargeback"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Route by payment type"
        },
        {
          "detail": "Do not return the bill to the patient. Set it aside, note date/time/patient and denomination, and verify with a detector pen or UV light against a second known-good bill.\n\nWhy: Passing a counterfeit bill along, even unknowingly, keeps the practice in the chain of custody and blocks any later law-enforcement report.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Isolate suspected counterfeit bill",
          "why": "Passing a counterfeit bill along, even unknowingly, keeps the practice in the chain of custody and blocks any later law-enforcement report."
        },
        {
          "detail": "Enter date, denomination, serial number if legible, patient account it was tied to, and staff member who caught it into the incident log.\n\nRecord: Incident log entry: date, denomination, serial number if legible, patient account it was tied to, staff member who caught it. File a report with local police if the practice's policy requires it for bills over a set threshold.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log and report the counterfeit bill"
        },
        {
          "detail": "Post the reversal entry and new balance to the patient ledger, dated and initialed by billing.\n\nRecord: Reversed payment amount, fee added (if any), and new account balance, dated and initialed.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Reconcile the patient account"
        },
        {
          "detail": "Office manager reviews the amount and circumstances before front desk or billing contacts the patient about a bounced check or stolen-card reversal.\n\nWhy: A wrongly-worded collection call over a bank error, versus genuine fraud, creates a different and more sensitive conversation — a supervisor sets the tone first.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor review before patient contact.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor review before patient contact",
          "why": "A wrongly-worded collection call over a bank error, versus genuine fraud, creates a different and more sensitive conversation — a supervisor sets the tone first."
        },
        {
          "detail": "Is the amount above the practice's write-off/escalation threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "opt-below",
              "label": "Below threshold — resolve as routine collection"
            },
            {
              "goto": "s13",
              "id": "opt-above",
              "label": "Above threshold or a repeat pattern — escalate"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the amount above the practice's write-off/escalation threshold?"
        },
        {
          "detail": "Explain the payment did not clear, state the new balance including any fee, and offer a corrected payment method.\n\nWhy: Most bounced checks and even some card holds are innocent errors, not fraud — treat the first contact as a billing correction, not an accusation.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the patient about the returned payment",
          "why": "Most bounced checks and even some card holds are innocent errors, not fraud — treat the first contact as a billing correction, not an accusation."
        },
        {
          "detail": "Write the final resolution and amount recovered into the incident log and close the ticket.\n\nRecord: Final resolution (paid, payment plan, write-off, referred), amount recovered, and date closed in the incident log.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Close the incident"
        },
        {
          "detail": "Incident resolved",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Incident resolved"
        },
        {
          "detail": "Back out the payment amount on the patient's account so the balance reflects reality, and note the NSF/returned-item fee if the bank charged one.\n\nWhy: The account must show the true unpaid balance before any patient contact happens.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Reverse the payment on the ledger",
          "why": "The account must show the true unpaid balance before any patient contact happens."
        },
        {
          "detail": "Pull the original transaction record (receipt, signature, or card-present confirmation) and submit it through the processor's dispute portal within the stated response window.\n\nWhy: Missing the response window forfeits the practice's right to contest the chargeback even if the original charge was legitimate.",
          "id": "s12",
          "kind": "step",
          "role": "billing",
          "title": "Respond to the processor's chargeback notice",
          "why": "Missing the response window forfeits the practice's right to contest the chargeback even if the original charge was legitimate."
        },
        {
          "detail": "Hand the owner the incident log, amount, and any prior history with this patient or payment method for a decision on collections, small-claims referral, or law-enforcement report.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the practice owner"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Counterfeit bill, bounced check or stolen-card payment detected — The bank returns a check, a bill is flagged counterfeit, or a card payment is reported stolen.",
      "title": "Counterfeit bill, bounced check or stolen-card payment detected",
      "trigger": "The bank returns a check, a bill is flagged counterfeit, or a card payment is reported stolen",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 — identity/payment-fraud detection program",
          "source": "FTC Red Flags Rule 16 CFR Part 681 — identity/payment-fraud detection program",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        },
        {
          "kind": "public_domain",
          "label": "FBI IC3 business email compromise guidance (public advisory)",
          "source": "FBI IC3 business email compromise guidance (public advisory)",
          "url": "https://www.ic3.gov/Media/Y2023/PSA230609"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fin-010",
      "kind": "operational",
      "materials": [
        "known-good vendor phone number (not from the suspicious email)",
        "bank contact for wire recall",
        "email headers for the suspicious message",
        "incident log template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Whoever received the request pauses before sending money or changing any vendor bank details, and flags it to a supervisor immediately.\n\nWhy: BEC attacks rely on urgency; the single most effective control is refusing to act inside the pressured window the email creates.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop — do not act on the payment instruction yet.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Stop — do not act on the payment instruction yet",
          "why": "BEC attacks rely on urgency; the single most effective control is refusing to act inside the pressured window the email creates."
        },
        {
          "detail": "Do not reply, forward, or delete. Screenshot or export the message with full headers for later review.\n\nWhy: Headers and the exact wording matter for the bank's fraud team and, if funds already moved, for a police report.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Preserve the suspicious message",
          "why": "Headers and the exact wording matter for the bank's fraud team and, if funds already moved, for a police report."
        },
        {
          "detail": "Call the vendor, lab, landlord or owner using a phone number from a prior invoice or the practice's own contact list — never a number provided in the suspicious email.\n\nWhy: A spoofed or compromised email account cannot spoof a call to a number the practice already had on file.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify by phone using a known-good number",
          "why": "A spoofed or compromised email account cannot spoof a call to a number the practice already had on file."
        },
        {
          "detail": "Did the callback confirm the request is legitimate?",
          "forks": [
            {
              "advised": false,
              "goto": "s11",
              "id": "opt-legit",
              "label": "Confirmed legitimate — proceed normally"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "opt-fraud",
              "label": "Not confirmed or contact denies sending it — treat as fraud"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the callback confirm the request is legitimate?"
        },
        {
          "detail": "Was money already sent under the fraudulent instruction?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "opt-not-sent",
              "label": "No funds sent yet — block and warn the team"
            },
            {
              "goto": "s12",
              "id": "opt-sent",
              "label": "Funds were already wired or paid — recall immediately"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Was money already sent under the fraudulent instruction?"
        },
        {
          "detail": "Do not act on the instruction, and alert front desk, billing, and the owner so no one else in the practice acts on a follow-up message.\n\nWhy: BEC actors often send a second, more urgent follow-up if the first attempt does not land.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Block the request and warn the team",
          "why": "BEC actors often send a second, more urgent follow-up if the first attempt does not land."
        },
        {
          "detail": "IT vendor checks whether the owner's or a vendor-facing staff email account shows signs of compromise (forwarding rules, login from unfamiliar location) and forces a password reset plus MFA if so.\n\nWhy: A single compromised mailbox is often the source of the spoofed request, and it stays exploitable until secured.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand off to IT for account security review",
          "why": "A single compromised mailbox is often the source of the spoofed request, and it stays exploitable until secured."
        },
        {
          "detail": "Owner reviews the full incident record and approves any resulting change to vendor payment verification policy (e.g. adding a dual-approval threshold).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off on incident closure and any policy change.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off on incident closure and any policy change"
        },
        {
          "detail": "Write the full timeline, amounts, and reference numbers into the incident log and close it.\n\nRecord: Timeline, amount at risk or lost, bank/IC3 report reference numbers, and any policy change adopted, filed in the incident log.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Close the incident"
        },
        {
          "detail": "Incident resolved",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Incident resolved"
        },
        {
          "detail": "Use the previously verified bank details on file, not the ones from the flagged email, and document the callback confirmation.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Process the payment through normal channels"
        },
        {
          "detail": "Call the practice's bank fraud line and request an emergency wire recall or ACH reversal, then file a report with the FBI's IC3 and local police.\n\nWhy: Recall requests have a real but shrinking chance of success measured in hours, not days — speed determines whether funds are recoverable.",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Contact the bank immediately for a wire recall",
          "why": "Recall requests have a real but shrinking chance of success measured in hours, not days — speed determines whether funds are recoverable."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Business email compromise or fraudulent payment instruction — A vendor, lab or landlord appears to email new bank details, or an urgent wire request arrives from the owner's address.",
      "title": "Business email compromise or fraudulent payment instruction",
      "trigger": "A vendor, lab or landlord appears to email new bank details, or an urgent wire request arrives from the owner's address",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681",
          "source": "FTC Red Flags Rule 16 CFR Part 681",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "fin-011",
      "kind": "operational",
      "materials": [
        "prior year's written Red Flags program",
        "list of red-flag incidents from the year",
        "new-account and payment-plan intake forms",
        "staff training sign-off sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Collect any cases where staff suspected or confirmed a patient was not who they claimed to be, or an account showed signs of medical identity theft, since the last review.\n\nWhy: The program must be updated based on real incidents, not just re-filed unchanged.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Gather this year's red-flag incidents",
          "why": "The program must be updated based on real incidents, not just re-filed unchanged."
        },
        {
          "detail": "Confirm the program still covers: (1) identifying relevant red flags for the practice's accounts and payment methods, (2) detecting them at account opening and in existing accounts, (3) responding appropriately to detected flags, and (4) updating the program periodically.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review the written program against required elements"
        },
        {
          "detail": "Does the program need updates?",
          "forks": [
            {
              "advised": false,
              "goto": "s5",
              "id": "opt-current",
              "label": "Program still fits current practices"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "opt-update",
              "label": "Gaps found (e.g. new payment-plan product, new intake method)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the program need updates?"
        },
        {
          "detail": "Add or revise red flags, detection steps, and response procedures to cover the gap (e.g. a new deferred-payment plan needs an identity-verification step at signup).\n\nWhy: The Red Flags Rule requires the program be tailored to the practice's actual size, complexity, and account types, not a generic template.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the written program",
          "why": "The Red Flags Rule requires the program be tailored to the practice's actual size, complexity, and account types, not a generic template."
        },
        {
          "detail": "Verify front desk and billing staff who open accounts or handle payment plans have completed red-flags awareness training this year; schedule a refresher session if not.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm annual staff training"
        },
        {
          "detail": "The Red Flags Rule requires initial approval and continued oversight of the program by the practice's owner or an appropriately designated senior employee.\n\nWhy: Approval at the ownership level is the accountability structure the rule itself specifies.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner or board-level approval of the program.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner or board-level approval of the program",
          "why": "Approval at the ownership level is the accountability structure the rule itself specifies."
        },
        {
          "detail": "Owner signs the current version of the written program, whether or not changes were made this cycle, confirming annual review occurred.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Sign and date the approved program"
        },
        {
          "detail": "File the signed program and training sign-off sheet, and calendar next year's review date.\n\nRecord: Dated, signed program on file; training sign-off sheet; next annual review date calendared.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the reviewed program and set next review date"
        },
        {
          "detail": "Annual review complete",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual review complete"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Identity theft prevention (Red Flags) written program and annual review — The annual review date, or the practice begins offering deferred payment plans.",
      "title": "Identity theft prevention (Red Flags) written program and annual review",
      "trigger": "The annual review date, or the practice begins offering deferred payment plans",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Red Flags Rule 16 CFR Part 681 (response-to-detected-red-flag requirement)",
          "source": "FTC Red Flags Rule 16 CFR Part 681 (response-to-detected-red-flag requirement)",
          "url": "https://www.ecfr.gov/current/title-16/part-681"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733 (claim-correction obligation)",
          "source": "False Claims Act 31 U.S.C. §3729–3733 (claim-correction obligation)",
          "url": "https://www.justice.gov/civil/false-claims-act"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fin-012",
      "kind": "operational",
      "materials": [
        "chart and billing history for the disputed date(s) of service",
        "patient identity-verification documents on file",
        "incident log",
        "payer contact for claim correction"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "compliance-officer",
        "office-manager",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Listen to what the patient says they were billed for or what appears on their insurance explanation of benefits that they do not recognize, and get it in writing if possible.\n\nWhy: A precise written account of the disputed charge is needed before anyone can investigate.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the patient's report",
          "why": "A precise written account of the disputed charge is needed before anyone can investigate."
        },
        {
          "detail": "Pass the patient's written report and account number to the compliance officer without discussing details further with the patient until it is reviewed.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the compliance officer"
        },
        {
          "detail": "Retrieve the clinical chart entry, sign-in log, and billing claim for the date(s) in question.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Pull the chart and billing records for the disputed date(s)"
        },
        {
          "detail": "Check the identity documents or verification method used at check-in that day against the patient's known identity (photo, prior signature, insurance card details).\n\nWhy: This determines whether someone else physically presented as the patient, or whether the error is a billing/coding mistake rather than identity theft.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compare identity-verification records",
          "why": "This determines whether someone else physically presented as the patient, or whether the error is a billing/coding mistake rather than identity theft."
        },
        {
          "detail": "Does this look like actual identity theft, or a billing error?",
          "forks": [
            {
              "goto": "s12",
              "id": "opt-error",
              "label": "Billing/coding error, not identity theft"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "opt-theft",
              "label": "Evidence someone else used the patient's identity — escalate to compliance"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does this look like actual identity theft, or a billing error?"
        },
        {
          "detail": "Compliance officer signs off on the corrective plan before any chart amendment or claim resubmission — this affects the medical record and a payer relationship, not just a bookkeeping entry.\n\nWhy: Amending a medical record incorrectly, or without proper flagging of the disputed entries, can create bigger problems than the original error.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before touching the chart or claim.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before touching the chart or claim",
          "why": "Amending a medical record incorrectly, or without proper flagging of the disputed entries, can create bigger problems than the original error."
        },
        {
          "detail": "Mark the disputed entries as under dispute rather than deleting them, and document what was verified as not belonging to the patient.\n\nWhy: Charts are legal records; entries get corrected or annotated, never silently erased.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Flag the disputed chart entries",
          "why": "Charts are legal records; entries get corrected or annotated, never silently erased."
        },
        {
          "detail": "Contact the payer to void or correct the claim tied to the fraudulent visit, per the payer's identity-theft dispute process.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Notify the payer and correct the claim"
        },
        {
          "detail": "Tell the patient what was found, what was corrected on their chart and with their payer, and recommend they also notify their insurer's fraud line and consider a credit freeze if applicable.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the patient of the resolution"
        },
        {
          "detail": "Write findings, chart flags, and payer correction reference into the incident log.\n\nRecord: Date reported, findings, chart flags applied, payer correction reference, and patient notification date, filed in the incident log.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident"
        },
        {
          "detail": "Dispute resolved",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Dispute resolved"
        },
        {
          "detail": "Fix the claim or statement and notify the patient the discrepancy was a clerical error, with an apology and corrected documentation.",
          "id": "s12",
          "kind": "step",
          "role": "billing",
          "title": "Correct the billing error"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Patient reports someone else used their identity or insurance at the practice — A patient or payer disputes services they did not receive.",
      "title": "Patient reports someone else used their identity or insurance at the practice",
      "trigger": "A patient or payer disputes services they did not receive",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "PCI Data Security Standard (open standard, PCI Security Standards Council)",
          "source": "PCI Data Security Standard (open standard, PCI Security Standards Council)",
          "url": "https://www.pcisecuritystandards.org/"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "fin-013",
      "kind": "operational",
      "materials": [
        "current PCI Self-Assessment Questionnaire (SAQ) type on file",
        "card terminal/network inventory",
        "processor's compliance portal login",
        "prior year's SAQ"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify which Self-Assessment Questionnaire type applies based on how the practice takes card payments (e.g. standalone terminal not connected to other systems vs. an integrated payment platform).\n\nWhy: The wrong SAQ type either under-scopes real risk or wastes time answering questions that do not apply.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Determine the applicable SAQ type",
          "why": "The wrong SAQ type either under-scopes real risk or wastes time answering questions that do not apply."
        },
        {
          "detail": "List every terminal, card reader, and software system that touches card data: front-desk terminal(s), online payment portal, any stored card-on-file feature.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Inventory card-accepting systems"
        },
        {
          "detail": "Verify the practice does not store full card numbers, CVV codes, or magnetic-stripe data anywhere outside the PCI-compliant processor's own vault (e.g. no card numbers written on paper forms kept on file, none typed into free-text notes).\n\nWhy: Storing raw card data outside the processor's compliant environment is the single most common and most serious PCI violation in small offices.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm no prohibited card data is stored",
          "why": "Storing raw card data outside the processor's compliant environment is the single most common and most serious PCI violation in small offices."
        },
        {
          "detail": "Was any prohibited storage found?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "opt-clean",
              "label": "No prohibited storage found"
            },
            {
              "goto": "s11",
              "id": "opt-found",
              "label": "Prohibited storage found"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was any prohibited storage found?"
        },
        {
          "detail": "Answer each SAQ question honestly against the inventory and storage findings above, working with the IT vendor on the technical questions.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete the Self-Assessment Questionnaire"
        },
        {
          "detail": "If the practice's SAQ type requires an external vulnerability scan (typically when payment systems connect to the internet), run it through an approved scanning vendor.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Run required vulnerability scan if applicable"
        },
        {
          "detail": "Compliance officer reviews the completed SAQ and any remediation notes before it is submitted to the processor.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before submission.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before submission"
        },
        {
          "detail": "Submit the signed questionnaire (and scan results if applicable) through the processor's compliance portal before the annual deadline.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the SAQ to the processor"
        },
        {
          "detail": "File the submitted SAQ and processor confirmation, and calendar next year's due date.\n\nRecord: Submitted SAQ, confirmation of processor acceptance, and next year's due date calendared.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "File the compliant SAQ and set next review date"
        },
        {
          "detail": "Annual PCI self-assessment complete",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Annual PCI self-assessment complete"
        },
        {
          "detail": "Securely destroy any paper or digital record containing full card numbers or CVVs, and retrain staff on the no-storage policy.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Remediate before completing the questionnaire"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Card data handling rules and annual PCI self-assessment questionnaire — The annual questionnaire date, or a new terminal or payment platform is installed.",
      "title": "Card data handling rules and annual PCI self-assessment questionnaire",
      "trigger": "The annual questionnaire date, or a new terminal or payment platform is installed",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Unclaimed Property Law (example: California CCP §1500 et seq. — dormancy periods and state reporting vary by state)",
          "source": "Unclaimed Property Law (example: California CCP §1500 et seq. — dormancy periods and state reporting vary by state)",
          "url": "https://www.sco.ca.gov/upd_rptg.html"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "fin-014",
      "kind": "operational",
      "materials": [
        "aged credit-balance report",
        "list of uncashed refund checks with issue dates",
        "state unclaimed-property reporting portal",
        "last-known patient contact info"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Run a report of all patient account credits and issued-but-uncashed refund checks older than the state's dormancy period (commonly 1–3 years depending on the property type and state).\n\nWhy: The dormancy clock, not the practice's convenience, determines when a credit becomes reportable.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Pull the aged credit-balance and uncashed-check report",
          "why": "The dormancy clock, not the practice's convenience, determines when a credit becomes reportable."
        },
        {
          "detail": "Send a due-diligence letter or make a documented attempt to reach the patient at their last-known address or phone before the state reporting deadline, as most states require.\n\nWhy: Reporting to the state is a last resort, not a shortcut — most escheat statutes require a documented good-faith attempt to return the money first.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Attempt patient contact (due diligence)",
          "why": "Reporting to the state is a last resort, not a shortcut — most escheat statutes require a documented good-faith attempt to return the money first."
        },
        {
          "detail": "Was the patient reached?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "opt-reached",
              "label": "Patient reached and claims the credit"
            },
            {
              "goto": "s7",
              "id": "opt-unreached",
              "label": "No response within the due-diligence window"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Was the patient reached?"
        },
        {
          "detail": "Issue or reissue the refund and close out the credit on the account.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Return the funds to the patient"
        },
        {
          "detail": "Write the disposition and confirmation number for each item into the escheat log.\n\nRecord: For each item: returned to patient or reported to state, confirmation number, and date, filed for future audit reference.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the outcome"
        },
        {
          "detail": "Escheat cycle complete",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Escheat cycle complete"
        },
        {
          "detail": "Compile each unreachable credit or uncashed check with patient name, last-known address, amount, and date the property became reportable, per the state's required format.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare the unclaimed-property report"
        },
        {
          "detail": "Owner reviews the report and approves remitting the total unclaimed amount to the state before it is filed.\n\nWhy: This is money leaving the practice's accounts on a compliance deadline, not a routine transaction — it gets an owner-level check.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review before filing and remitting funds.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review before filing and remitting funds",
          "why": "This is money leaving the practice's accounts on a compliance deadline, not a routine transaction — it gets an owner-level check."
        },
        {
          "detail": "Submit the report through the state's unclaimed-property portal and remit the total amount by the statutory deadline.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "File the report and remit funds to the state"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Unclaimed patient credits and uncashed refunds — due diligence and state reporting — A refund check is uncashed past the dormancy period, or the annual report date approaches.",
      "title": "Unclaimed patient credits and uncashed refunds — due diligence and state reporting",
      "trigger": "A refund check is uncashed past the dormancy period, or the annual report date approaches",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "IRS Form 8300 cash reporting requirement 26 U.S.C. §6050I; 31 U.S.C. §5331",
          "source": "IRS Form 8300 cash reporting requirement 26 U.S.C. §6050I; 31 U.S.C. §5331",
          "url": "https://www.irs.gov/businesses/small-businesses-self-employed/form-8300-and-reporting-cash-payments-of-over-10000"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fin-015",
      "kind": "operational",
      "materials": [
        "IRS Form 8300",
        "patient identifying information (name, address, SSN or ITIN, ID type)",
        "transaction ledger showing dates and amounts",
        "certified-mail or e-file confirmation"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify a single cash payment over $10,000, or multiple cash payments from the same patient within a 12-month period for related treatment that together exceed $10,000.\n\nWhy: The rule aggregates related transactions, so a patient paying $6,000 cash today and $5,000 cash next month for the same treatment plan is still reportable.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Detect a reportable cash payment",
          "why": "The rule aggregates related transactions, so a patient paying $6,000 cash today and $5,000 cash next month for the same treatment plan is still reportable."
        },
        {
          "detail": "Currency, cashier's checks, money orders, and traveler's checks under $10,000 each generally count as cash for this rule; a personal check, wire transfer, or credit card payment generally does not.\n\nWhy: Filing on a non-cash payment, or missing a cashier's-check payment that does count, are both common errors.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Confirm the payment meets the definition of \"cash\"",
          "why": "Filing on a non-cash payment, or missing a cashier's-check payment that does count, are both common errors."
        },
        {
          "detail": "Is this a reportable transaction?",
          "forks": [
            {
              "goto": "s11",
              "id": "opt-no",
              "label": "Does not meet the cash or dollar definition"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "opt-yes",
              "label": "Meets the reporting threshold — proceed to filing"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Is this a reportable transaction?"
        },
        {
          "detail": "Obtain the payer's name, address, taxpayer identification number (SSN or ITIN), and identification document details as required on Form 8300.\n\nWhy: The form cannot be completed or filed without this information, and it must come from the actual person making the payment.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Collect the patient's identifying information",
          "why": "The form cannot be completed or filed without this information, and it must come from the actual person making the payment."
        },
        {
          "detail": "Fill in the transaction details: date, amount, method of payment, and description of the property or services (dental treatment).",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Complete Form 8300"
        },
        {
          "detail": "Owner reviews the completed form for accuracy and signs it before filing — this is a federal filing with legal consequences for errors or omissions.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review and signature before filing.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review and signature before filing"
        },
        {
          "detail": "E-file through the IRS's system, or mail the paper form, within 15 days of receiving the reportable cash payment.\n\nWhy: The 15-day window is a hard statutory deadline; late filing carries penalties even if the form is otherwise correct.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "File within 15 days of the transaction",
          "why": "The 15-day window is a hard statutory deadline; late filing carries penalties even if the form is otherwise correct."
        },
        {
          "detail": "By January 31 of the year following the transaction, send the patient a written statement that a Form 8300 was filed reporting the payment, as required by law.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Send the required patient notification"
        },
        {
          "detail": "File the copy of the filed form, confirmation, and notification letter in the compliance archive.\n\nRecord: Copy of the filed form, e-file or mail confirmation, and patient notification letter, retained per the required record-keeping period.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Retain the filing record"
        },
        {
          "detail": "Form 8300 filed and documented",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Form 8300 filed and documented"
        },
        {
          "detail": "Not reportable — no filing required",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Not reportable — no filing required"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Cash payment over $10,000 — Form 8300 filing within 15 days — A patient pays more than $10,000 in cash for a case, in one or related transactions.",
      "title": "Cash payment over $10,000 — Form 8300 filing within 15 days",
      "trigger": "A patient pays more than $10,000 in cash for a case, in one or related transactions",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; CMS Medicaid provider audit rules 42 CFR Part 455",
          "source": "False Claims Act 31 U.S.C. §3729–3733; CMS Medicaid provider audit rules 42 CFR Part 455",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "California overpayment recoupment limits, H&S §1371.1 (health care service plans) / Ins. Code §10123.145 (disability insurers) — provider must reimburse or contest within 30 working days of notice",
          "repaired": {
            "action": "replace",
            "evidence": "Whenever a health care service plan ... determines that a provider has been overpaid ... the provider shall reimburse the plan within 30 working days of receipt of the notice of overpayment, unless the overpayment is contested by the provider ... in which case the provider shall notify the plan in writing within 30 working days.",
            "ticket": "PROT-017",
            "was": {
              "source": "California overpayment recoupment limits H&S §1371.1 / Ins. Code §10123.145 (state-specific timing rules apply)",
              "url": "https://www.sco.ca.gov/upd_rptg.html"
            }
          },
          "source": "CA H&S §1371.1",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=1371.1"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "fin-016",
      "kind": "operational",
      "materials": [
        "payer's audit or records-request letter",
        "list of claims/patients under review",
        "full charts and radiographs for each requested claim",
        "response deadline calendar"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "dentist",
        "office-manager",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Record the payer, the claims or date range in scope, the stated deadline for response, and whether this is a routine sample audit or a for-cause post-payment review.\n\nWhy: The deadline is the single most consequence-bearing fact — missing it can convert a routine sample audit into a presumption against the practice.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Log the audit or records request",
          "why": "The deadline is the single most consequence-bearing fact — missing it can convert a routine sample audit into a presumption against the practice."
        },
        {
          "detail": "Pass the full request letter and deadline to the compliance officer to own the response.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand off to the compliance officer"
        },
        {
          "detail": "Pull in billing (claims history), the treating dentist(s) named in the requested charts, and office manager, and calendar internal checkpoints ahead of the payer's deadline.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Assemble the internal review team"
        },
        {
          "detail": "Assemble clinical notes, radiographs, treatment plan, and billing documentation exactly as they exist in the record — nothing added or altered.\n\nWhy: Amending a chart after an audit request is discovered looks like, and can be treated as, evidence tampering, even if the intent was innocent correction.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Pull the complete chart for each requested claim",
          "why": "Amending a chart after an audit request is discovered looks like, and can be treated as, evidence tampering, even if the intent was innocent correction."
        },
        {
          "detail": "The treating dentist reviews whether the chart supports the billed code — diagnosis, necessity, and procedure documented — and flags any claim where documentation looks thin.\n\nWhy: The dentist who provided the care is best positioned to know whether the clinical picture actually supports what was billed.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Clinician reviews own documentation for completeness",
          "why": "The dentist who provided the care is best positioned to know whether the clinical picture actually supports what was billed."
        },
        {
          "detail": "The treating dentist signs off on the accuracy and completeness of the clinical documentation being submitted before it goes to the payer.\n\nWhy: This is a clinical-billing consequential step — records supporting a coded, billed claim never go out without the licensed provider's review (CLAUDE.md #4).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before submission to the payer.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before submission to the payer",
          "why": "This is a clinical-billing consequential step — records supporting a coded, billed claim never go out without the licensed provider's review (CLAUDE.md #4)."
        },
        {
          "detail": "Send the compiled records to the payer through their required channel (portal, mail, or secure fax) before the stated deadline, keeping a copy and delivery confirmation.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Submit the response by the deadline"
        },
        {
          "detail": "Payers typically take 4–8 weeks to issue findings after records are submitted (duration set to the 4-week low end; track the expected response date and extend up to ~8 weeks/80640 minutes if not yet received).",
          "id": "s8",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 2419200,
          "title": "Await the payer's audit findings"
        },
        {
          "detail": "What did the payer find?",
          "forks": [
            {
              "goto": "s15",
              "id": "opt-clean",
              "label": "No findings against the practice"
            },
            {
              "advised": true,
              "goto": "s10",
              "id": "opt-recoup",
              "label": "Recoupment or denial findings issued — review before accepting"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What did the payer find?"
        },
        {
          "detail": "Does the practice agree with the findings, or appeal?",
          "forks": [
            {
              "advised": false,
              "goto": "s16",
              "id": "opt-agree",
              "label": "Findings are correct — accept and refund/adjust"
            },
            {
              "advised": true,
              "goto": "s11",
              "id": "opt-appeal",
              "label": "Findings are disputed — file an appeal within the stated window"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the practice agree with the findings, or appeal?"
        },
        {
          "detail": "Owner reviews the disputed findings and the appeal basis, and decides whether to file internally or retain outside counsel/a dental billing consultant for a complex or high-dollar appeal.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review before filing an appeal.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review before filing an appeal"
        },
        {
          "detail": "Submit the written appeal with supporting clinical rationale and any additional documentation, before the payer's appeal deadline expires.\n\nWhy: Appeal windows are typically short and non-extendable; missing it forfeits the right to contest even a wrong finding.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the appeal within the payer's stated window",
          "why": "Appeal windows are typically short and non-extendable; missing it forfeits the right to contest even a wrong finding."
        },
        {
          "detail": "File the final outcome, amount recouped or retained, and full document trail in the compliance archive.\n\nRecord: Final outcome (accepted, appealed, appeal result), amount recouped or retained, and full document trail filed for the required retention period.",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the audit record"
        },
        {
          "detail": "Payer audit resolved",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Payer audit resolved"
        },
        {
          "detail": "File the payer's closure letter and internal review notes.\n\nRecord: Audit closure letter from payer and internal review notes filed.",
          "id": "s15",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the audit with no findings"
        },
        {
          "detail": "Billing processes the agreed recoupment through the payer's normal offset or refund process and adjusts internal records.",
          "id": "s16",
          "kind": "step",
          "role": "billing",
          "title": "Hand off to billing for repayment or claim adjustment"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Insurance payer audit, records request or post-payment review response — A payer requests charts for a sample of claims or announces a post-payment audit.",
      "title": "Insurance payer audit, records request or post-payment review response",
      "trigger": "A payer requests charts for a sample of claims or announces a post-payment audit",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Health & Safety Code §1371.1 — health-plan overpayment-notice/refund-dispute timing only",
          "repaired": {
            "action": "reduce",
            "evidence": "The audit's own verification (via search) confirms H&S §1371.1 governs health-plan-to-provider overpayment notice, 30-day response, and interest-accrual rules — matching fin-017's subject exactly. The bundled URL (sco.ca.gov/upd_rptg.html) is the State Controller's Unclaimed Property reporting page and addresses escheatment, not any of the three protocols' subjects.",
            "ticket": "PROT-017",
            "was": {
              "source": "California overpayment recoupment limits H&S §1371.1 / Ins. Code §10123.145; Unclaimed Property Law CCP §1500 et seq.; Rosenthal Act Civ. Code §1788",
              "url": "https://www.sco.ca.gov/upd_rptg.html"
            }
          },
          "source": "Cal. Health & Safety Code §1371.1 (health-plan-to-provider overpayment notice, statutory time limits, interest accrual). Scope: fin-017 (payer overpayment notice — verification, statutory time limits, refund or dispute) only — does NOT reach fin-003 (patient demands a refund for treatment/prepayment) or fin-025 (patient bankruptcy notice), which are not overpayment-recoupment matters. Drops the Unclaimed Property Law citation and its URL (sco.ca.gov/upd_rptg.html is the State Controller's unclaimed-property page and supports none of the three protocols) and drops the Rosenthal Fair Debt Collection Act (Civ. Code §1788, which governs debt-collection conduct, not refund/overpayment mechanics).",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1371.1&lawCode=HSC"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; CMS Medicare dental coverage and opt-out 42 CFR 405.400 et seq.; Medicaid provider rules 42 CFR Part 455",
          "source": "False Claims Act 31 U.S.C. §3729–3733; CMS Medicare dental coverage and opt-out 42 CFR 405.400 et seq.; Medicaid provider rules 42 CFR Part 455",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "California overpayment notice content and 30-day contest window H&S §1371.1(a)-(c) — a payer may not recoup without a written explanation and a right to contest",
          "source": "California overpayment notice content and 30-day contest window H&S §1371.1(a)-(c) — a payer may not recoup without a written explanation and a right to contest",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1371.1.&lawCode=HSC"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fin-017",
      "kind": "operational",
      "materials": [
        "overpayment notice / letter from payer",
        "claim and remittance history for the patient",
        "ledger card / account history",
        "payer provider manual or contract",
        "recoupment log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Date-stamp the notice, record the payer, patient, claim number, amount demanded, and stated reason (duplicate payment, coordination of benefits, coding error, eligibility). Enter it in the recoupment log with a due date.\n\nWhy: Statutory response windows (e.g. a 30-day contest period under California H&S §1371.1) run from the date of the notice, not the date it is noticed — an undated intake is how deadlines get missed.\n\nRecord: recoupment log entry: payer, patient, claim #, amount, reason, due date",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Log the overpayment notice on arrival",
          "why": "Statutory response windows (e.g. a 30-day contest period under California H&S §1371.1) run from the date of the notice, not the date it is noticed — an undated intake is how deadlines get missed."
        },
        {
          "detail": "Pull the original claim, the remittance advice that paid it, and the treatment record. Confirm whether the service was billed once, matches the chart, and whether a second payer (coordination of benefits) also paid.\n\nWhy: A meaningful share of overpayment demands are themselves wrong — duplicate-payment claims are the most common false positive.\n\nRecord: verification worksheet attached to the claim",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Verify the claim against the chart and remittance history",
          "why": "A meaningful share of overpayment demands are themselves wrong — duplicate-payment claims are the most common false positive."
        },
        {
          "detail": "Is the overpayment claim valid?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "valid",
              "label": "Payer is correct — an overpayment occurred"
            },
            {
              "goto": "s10",
              "id": "invalid",
              "label": "Records show the payer is wrong"
            },
            {
              "goto": "s13",
              "id": "unclear",
              "label": "Cannot determine from available records"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Is the overpayment claim valid?"
        },
        {
          "detail": "Identify the applicable time limit for the payer to demand recoupment (state insurance code limits, e.g. one year for most California overpayment claims under Ins. Code §10123.145, shorter for Medicare/Medicaid overpayments) and the practice's window to respond or contest.\n\nWhy: Many state laws cap how far back a payer may reach for recoupment; a demand outside that window can be challenged on timeliness alone.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Check the statutory or contractual recoupment window",
          "why": "Many state laws cap how far back a payer may reach for recoupment; a demand outside that window can be challenged on timeliness alone."
        },
        {
          "detail": "Is the payer's demand within its allowed time window and did it include required contest-rights language?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "compliant",
              "label": "Timely and compliant — proceed to refund or agreed offset"
            },
            {
              "goto": "s10",
              "id": "late",
              "label": "Outside the statutory window or missing required notice content"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "billing",
          "title": "Is the payer's demand within its allowed time window and did it include required contest-rights language?"
        },
        {
          "detail": "The practice owner approves the refund method (check, or offset against future claim payments) and the amount before billing executes it.\n\nWhy: Refunds and offsets move practice money and affect the day's deposit reconciliation — a named approver keeps this out of a single staff member's unreviewed discretion.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before refund or offset is accepted.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before refund or offset is accepted",
          "why": "Refunds and offsets move practice money and affect the day's deposit reconciliation — a named approver keeps this out of a single staff member's unreviewed discretion."
        },
        {
          "detail": "Issue the refund check to the payer or acknowledge the offset against a future remittance. Update the patient ledger to reflect the corrected balance.\n\nWhy: The patient's account of record must match what actually happened, or the next statement will misstate their balance.\n\nRecord: ledger adjustment and payment/offset record",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Process the refund or accept the offset",
          "why": "The patient's account of record must match what actually happened, or the next statement will misstate their balance."
        },
        {
          "detail": "Record the final outcome (paid, offset, reduced, withdrawn), amount, and date closed in the recoupment log; note the reason if disputed and won or lost.\n\nWhy: A payer that repeatedly issues incorrect overpayment demands is a pattern worth tracking — the log is the only record that reveals it.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Close out the recoupment log entry",
          "why": "A payer that repeatedly issues incorrect overpayment demands is a pattern worth tracking — the log is the only record that reveals it."
        },
        {
          "detail": "Overpayment notice resolved",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Overpayment notice resolved"
        },
        {
          "detail": "Draft a letter citing the specific basis (records mismatch, coordination-of-benefits error, statutory time bar, missing required notice content) with copies of supporting documentation attached. Send within the payer's stated appeal window.\n\nWhy: An undisputed demand is treated as accepted after the response window closes — silence is not a safe default.\n\nRecord: dispute letter and attachments filed in recoupment log",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Prepare a written dispute or appeal",
          "why": "An undisputed demand is treated as accepted after the response window closes — silence is not a safe default."
        },
        {
          "detail": "The practice owner reviews the dispute letter and supporting basis before it is mailed or submitted through the payer portal.\n\nWhy: A rejected dispute can trigger escalated recoupment (offset against future claims) — the owner should see the position being taken before it goes out.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review before the dispute is sent.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review before the dispute is sent",
          "why": "A rejected dispute can trigger escalated recoupment (offset against future claims) — the owner should see the position being taken before it goes out."
        },
        {
          "detail": "Payer response to the dispute",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "upheld",
              "label": "Payer withdraws or reduces the demand"
            },
            {
              "goto": "s6",
              "id": "denied",
              "label": "Payer denies the dispute and maintains the demand"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "billing",
          "title": "Payer response to the dispute"
        },
        {
          "detail": "Forward the notice, claim, and verification worksheet to the practice owner with the specific question that could not be resolved from records on hand.\n\nWhy: Ambiguous cases risk either paying a claim that was wrong or missing a real deadline — a practice-level decision, not a line-staff one.",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "Hand unresolved verification to the practice owner",
          "why": "Ambiguous cases risk either paying a claim that was wrong or missing a real deadline — a practice-level decision, not a line-staff one."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Payer overpayment notice — verification, statutory time limits, refund or dispute — A payer demands a refund or offsets future payments.",
      "title": "Payer overpayment notice — verification, statutory time limits, refund or dispute",
      "trigger": "A payer demands a refund or offsets future payments",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Medicaid provider enrollment and revalidation 42 CFR Part 455 Subpart E",
          "source": "Medicaid provider enrollment and revalidation 42 CFR Part 455 Subpart E",
          "url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455"
        },
        {
          "kind": "regulation",
          "label": "CMS Medicare dental coverage and opt-out 42 CFR 405.400 et seq.",
          "source": "CMS Medicare dental coverage and opt-out 42 CFR 405.400 et seq.",
          "url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405"
        },
        {
          "kind": "regulation",
          "label": "California Medi-Cal Dental (Denti-Cal) provider enrollment and revalidation requirements",
          "source": "California Medi-Cal Dental (Denti-Cal) provider enrollment and revalidation requirements",
          "url": "https://www.dhcs.ca.gov/provgovpart/Pages/DentiCal.aspx"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "fin-018",
      "kind": "operational",
      "materials": [
        "NPI and state license documentation",
        "program enrollment or revalidation portal access",
        "current fee schedule and covered-services bulletin",
        "revalidation tracking calendar",
        "provider agreement / bulletin archive folder"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "billing",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "What triggered this cycle?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-enroll",
              "label": "New enrollment"
            },
            {
              "goto": "s7",
              "id": "revalidation",
              "label": "Revalidation due"
            },
            {
              "goto": "s12",
              "id": "bulletin",
              "label": "Program bulletin changed billing rules"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "What triggered this cycle?"
        },
        {
          "detail": "Confirm current NPI (Type 1 individual and Type 2 organization if applicable), state dental license, DEA registration if prescribing, malpractice insurance certificate, W-9, and business address/banking details for the enrollment application.\n\nWhy: Public program applications reject on missing or mismatched identifiers more often than on substantive eligibility — a complete packet on first submission avoids a restart of the review clock.\n\nRecord: enrollment document checklist, completed copy filed",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather documentation for new enrollment",
          "why": "Public program applications reject on missing or mismatched identifiers more often than on substantive eligibility — a complete packet on first submission avoids a restart of the review clock."
        },
        {
          "detail": "The compliance officer reviews ownership and control disclosures, NPI, license and DEA identifiers for accuracy before the new enrollment application is submitted.\n\nWhy: False or omitted ownership disclosures on a public-program enrollment form can itself be a basis for exclusion — this risk applies at least as much to a first-time application as it does to a revalidation (see sign-off-revalidate below).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review of ownership/control disclosures before first submission.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review of ownership/control disclosures before first submission",
          "why": "False or omitted ownership disclosures on a public-program enrollment form can itself be a basis for exclusion — this risk applies at least as much to a first-time application as it does to a revalidation (see sign-off-revalidate below)."
        },
        {
          "detail": "Complete the state Medicaid/dental program provider enrollment application online or by paper per program instructions; retain a confirmation number or submission receipt.\n\nWhy: Enrollment effective dates typically run from submission or approval date, not from when the practice starts seeing beneficiaries — late submission means unbillable services in the gap.\n\nRecord: submission confirmation number and date",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the enrollment application through the program portal",
          "why": "Enrollment effective dates typically run from submission or approval date, not from when the practice starts seeing beneficiaries — late submission means unbillable services in the gap."
        },
        {
          "detail": "Record the current enrollment status, effective dates, and the next revalidation or bulletin-review checkpoint on the tracking calendar.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the enrollment/revalidation tracking calendar"
        },
        {
          "detail": "Public program enrollment cycle complete",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Public program enrollment cycle complete"
        },
        {
          "detail": "Confirm the program's revalidation cycle (commonly every 3–5 years for Medicaid providers) and the specific deadline shown on the tracking calendar or portal notice.\n\nWhy: Missed revalidation deactivates the provider's ability to bill the program, and reactivation is not always retroactive.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the revalidation deadline and required revalidation cycle",
          "why": "Missed revalidation deactivates the provider's ability to bill the program, and reactivation is not always retroactive."
        },
        {
          "detail": "Is the revalidation deadline more than 30 days out?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "time",
              "label": "Yes — time to prepare the packet normally"
            },
            {
              "goto": "s14",
              "id": "urgent",
              "label": "No — deadline is imminent or passed"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the revalidation deadline more than 30 days out?"
        },
        {
          "detail": "Update NPI, license renewal date, malpractice coverage certificate, ownership/control disclosures, and any address or banking changes since last enrollment.\n\nWhy: Revalidation re-verifies the same identifiers as initial enrollment — anything that changed since the last cycle (address, ownership, license renewal) must be re-attested.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather documentation for revalidation",
          "why": "Revalidation re-verifies the same identifiers as initial enrollment — anything that changed since the last cycle (address, ownership, license renewal) must be re-attested."
        },
        {
          "detail": "The compliance officer reviews ownership and control disclosures for accuracy before the revalidation packet is submitted.\n\nWhy: False or omitted ownership disclosures on a public-program enrollment form can itself be a basis for exclusion — this is a compliance-sensitive attestation, not routine paperwork.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review of ownership/control disclosures before submission.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review of ownership/control disclosures before submission",
          "why": "False or omitted ownership disclosures on a public-program enrollment form can itself be a basis for exclusion — this is a compliance-sensitive attestation, not routine paperwork."
        },
        {
          "detail": "Submit through the program portal or by mail per program instructions; retain confirmation and diary the next revalidation cycle date immediately.\n\nWhy: Setting the next reminder now, while the current cycle is fresh, is what prevents the next cycle from becoming another urgent escalation.\n\nRecord: submission confirmation; next revalidation date added to tracking calendar",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the revalidation packet",
          "why": "Setting the next reminder now, while the current cycle is fresh, is what prevents the next cycle from becoming another urgent escalation."
        },
        {
          "detail": "Read the bulletin for changes to covered procedure codes, fee schedule, frequency limits, prior-authorization requirements, or documentation standards effective as of a stated date.\n\nWhy: Billing to outdated program rules is a common source of claim denials and, if uncorrected at volume, can look like a pattern of improper billing.",
          "id": "s12",
          "kind": "step",
          "role": "billing",
          "title": "Review a new program bulletin for billing rule changes",
          "why": "Billing to outdated program rules is a common source of claim denials and, if uncorrected at volume, can look like a pattern of improper billing."
        },
        {
          "detail": "Summarize what changed and its effective date; update fee schedule references and any chairside coding guides used by the dentist and billing team.\n\nWhy: A rule change that reaches billing but not the clinician (or vice versa) produces claims coded to the old rule until someone notices the denial pattern.\n\nRecord: internal rule-change notice, date acknowledged by billing and dentist",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "Communicate the rule change to billing and clinical staff",
          "why": "A rule change that reaches billing but not the clinician (or vice versa) produces claims coded to the old rule until someone notices the denial pattern."
        },
        {
          "detail": "Notify the practice owner immediately with the deadline status and the estimated revenue exposure from a billing gap if enrollment lapses.\n\nWhy: A lapsed enrollment stops payment on every claim to that program until it is cured — the owner needs to know before it happens, not after the first denied claim.",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate an at-risk or missed revalidation to the practice owner",
          "why": "A lapsed enrollment stops payment on every claim to that program until it is cured — the owner needs to know before it happens, not after the first denied claim."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Medicaid or state dental program enrollment, revalidation and program rules — The practice enrolls, revalidation is due, or a program bulletin changes billing rules.",
      "title": "Medicaid or state dental program enrollment, revalidation and program rules",
      "trigger": "The practice enrolls, revalidation is due, or a program bulletin changes billing rules",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733 (qui tam and whistleblower protection provisions)",
          "source": "False Claims Act 31 U.S.C. §3729–3733 (qui tam and whistleblower protection provisions)",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "regulation",
          "label": "Medicaid provider compliance program requirements 42 CFR Part 455 Subpart A",
          "source": "Medicaid provider compliance program requirements 42 CFR Part 455 Subpart A",
          "url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455"
        },
        {
          "kind": "public_domain",
          "label": "OIG Compliance Program Guidance for Individual and Small Group Physician Practices (applied by analogy to dental practices billing public programs)",
          "source": "OIG Compliance Program Guidance for Individual and Small Group Physician Practices (applied by analogy to dental practices billing public programs)",
          "url": "https://oig.hhs.gov/compliance/compliance-guidance/"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "fin-019",
      "kind": "operational",
      "materials": [
        "fraud-waste-abuse training slide deck or module",
        "attendance/completion log",
        "anonymous reporting channel instructions (hotline, form, or email)",
        "sample scenarios for discussion",
        "written non-retaliation policy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "billing",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "What triggered this cycle?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "annual",
              "label": "Annual training date"
            },
            {
              "goto": "s6",
              "id": "incident",
              "label": "An employee was asked to bill for a service not rendered"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What triggered this cycle?"
        },
        {
          "detail": "Set a date covering all staff who touch billing, scheduling, or clinical documentation; confirm the training module or deck is current for the year's program rules.\n\nWhy: Program bulletins and coding rules change year to year — training content that is not refreshed teaches last year's rules.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the annual fraud-waste-abuse training session",
          "why": "Program bulletins and coding rules change year to year — training content that is not refreshed teaches last year's rules."
        },
        {
          "detail": "Cover: what constitutes fraud (billing for services not rendered, upcoding, unbundling), what constitutes waste and abuse (medically unnecessary services, documentation shortcuts), the anonymous reporting channel and how to use it, and the written non-retaliation policy protecting anyone who reports in good faith.\n\nWhy: Staff cannot report what they cannot recognize — the training's job is to make the boundary between aggressive billing and improper billing concrete, not abstract.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Deliver training covering the required topics",
          "why": "Staff cannot report what they cannot recognize — the training's job is to make the boundary between aggressive billing and improper billing concrete, not abstract."
        },
        {
          "detail": "Log each attendee's name, role, and completion date in the attendance log.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record training completion"
        },
        {
          "detail": "Annual training cycle complete",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual training cycle complete"
        },
        {
          "detail": "The employee's account of being asked to bill for a service not rendered is routed to the compliance officer for a documented review — it is not to be waved off or settled verbally by the person who made the request.\n\nWhy: A verbal-only resolution leaves no record if the pattern recurs or if the reporting employee later faces retaliation — the reporting channel exists precisely so this does not depend on one conversation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the employee's report is directed to the compliance officer, not resolved informally.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm the employee's report is directed to the compliance officer, not resolved informally",
          "why": "A verbal-only resolution leaves no record if the pattern recurs or if the reporting employee later faces retaliation — the reporting channel exists precisely so this does not depend on one conversation."
        },
        {
          "detail": "Document what was asked, by whom, for which patient/claim (without recording unnecessary PHI beyond the claim reference needed to investigate), and when. Reassure the reporting employee of the non-retaliation policy in writing.\n\nWhy: A precise, dated account is what makes the difference between an investigable report and a vague recollection months later.\n\nRecord: confidential intake record",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Take a confidential intake of the report",
          "why": "A precise, dated account is what makes the difference between an investigable report and a vague recollection months later."
        },
        {
          "detail": "Pull the claim or intended claim, the chart, and any communication about the request. Determine whether the instruction was a misunderstanding, a one-off error, or a directive to bill improperly.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Investigate the underlying billing request"
        },
        {
          "detail": "What does the investigation show?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "error",
              "label": "Misunderstanding or isolated error — correct and document"
            },
            {
              "goto": "s12",
              "id": "pattern",
              "label": "Evidence of an intentional or repeated improper billing directive"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What does the investigation show?"
        },
        {
          "detail": "Ensure the claim is billed correctly (or not submitted), and clarify the applicable billing rule with the staff member who made or received the request.\n\nRecord: corrective action note in reporting log",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Correct the claim and clarify the rule with the involved staff"
        },
        {
          "detail": "Report investigated and closed",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Report investigated and closed"
        },
        {
          "detail": "Present the investigation findings to the practice owner; a pattern of intentional improper billing may require legal counsel and, depending on scope, self-disclosure consideration (see fin-021).\n\nWhy: A confirmed pattern is a False Claims Act exposure question that belongs at the ownership level, not resolved by the compliance officer alone.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escalate a confirmed improper billing directive to the practice owner",
          "why": "A confirmed pattern is a False Claims Act exposure question that belongs at the ownership level, not resolved by the compliance officer alone."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Fraud, waste and abuse training and internal reporting channel — The annual training date, or an employee is asked to bill for a service not rendered.",
      "title": "Fraud, waste and abuse training and internal reporting channel",
      "trigger": "The annual training date, or an employee is asked to bill for a service not rendered",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "CMS Medicare dental coverage and opt-out 42 CFR 405.400 et seq.",
          "source": "CMS Medicare dental coverage and opt-out 42 CFR 405.400 et seq.",
          "url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405"
        },
        {
          "kind": "regulation",
          "label": "CMS guidance on Medicare dental services coverage exceptions and physician/practitioner opt-out",
          "source": "CMS guidance on Medicare dental services coverage exceptions and physician/practitioner opt-out",
          "url": "https://www.cms.gov/medicare/coverage/dental-services"
        },
        {
          "kind": "regulation",
          "label": "CMS Part D prescriber enrollment / order-and-refer requirement",
          "source": "CMS Part D prescriber enrollment / order-and-refer requirement",
          "url": "https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers/other-provider-supplier"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fin-020",
      "kind": "operational",
      "materials": [
        "CMS Medicare provider enrollment forms (855I or opt-out affidavit)",
        "list of Medicare-covered dental circumstances (e.g. jaw reconstruction following accident, extractions prior to radiation therapy)",
        "Part D prescriber enrollment or order-and-refer status reference",
        "patient communication template for billing status"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "billing",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check whether the planned service is one of the narrow circumstances where Medicare covers dental care (e.g. extractions required before radiation therapy for cancer of the jaw, reconstruction following accidental injury, or a hospital-inpatient dental procedure where the underlying condition is covered) rather than routine dental care, which Medicare does not cover.\n\nWhy: Medicare's dental exclusion is broad; the question is not 'is the patient a Medicare beneficiary' but 'does this specific service fall under one of the narrow covered exceptions.'",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify whether the service falls under a Medicare-covered dental exception",
          "why": "Medicare's dental exclusion is broad; the question is not 'is the patient a Medicare beneficiary' but 'does this specific service fall under one of the narrow covered exceptions.'"
        },
        {
          "detail": "Does the service fall under a Medicare-covered exception, or is this a prescription needing Part D order-and-refer status?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "covered",
              "label": "Yes — service may be Medicare-covered"
            },
            {
              "goto": "s7",
              "id": "rx-only",
              "label": "No covered service, but a Part D prescription is involved"
            },
            {
              "goto": "s9",
              "id": "not-covered",
              "label": "Routine dental care, not covered"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the service fall under a Medicare-covered exception, or is this a prescription needing Part D order-and-refer status?"
        },
        {
          "detail": "Confirm whether the practice/dentist is currently a Medicare-enrolled provider, has filed a valid opt-out affidavit, or has neither status on file.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Check the practice's current Medicare enrollment status"
        },
        {
          "detail": "What is the current status?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "enrolled",
              "label": "Already enrolled as a Medicare provider"
            },
            {
              "goto": "s10",
              "id": "opted-out",
              "label": "Valid opt-out affidavit on file"
            },
            {
              "goto": "s11",
              "id": "neither",
              "label": "Neither enrolled nor opted out"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "What is the current status?"
        },
        {
          "detail": "Submit the claim to Medicare using the applicable dental exception documentation supporting medical necessity.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Bill Medicare for the covered service"
        },
        {
          "detail": "Medicare status determination complete",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Medicare status determination complete"
        },
        {
          "detail": "Confirm the prescribing dentist is enrolled or validly opted-out for order-and-refer purposes so the prescription can be filled under the patient's Part D plan.\n\nWhy: A Part D pharmacy claim can reject at the counter if the prescriber lacks a current order-and-refer enrollment record, even when the dentist never bills Medicare directly.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Confirm order-and-refer enrollment status for Part D prescribing",
          "why": "A Part D pharmacy claim can reject at the counter if the prescriber lacks a current order-and-refer enrollment record, even when the dentist never bills Medicare directly."
        },
        {
          "detail": "Is order-and-refer status current?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "current",
              "label": "Current — proceed with prescription"
            },
            {
              "goto": "s11",
              "id": "lapsed",
              "label": "Lapsed or never filed"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "billing",
          "title": "Is order-and-refer status current?"
        },
        {
          "detail": "Inform the patient the service is routine dental care not covered by Medicare and provide the practice's standard fee estimate.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Provide a self-pay notice for non-covered routine care"
        },
        {
          "detail": "Under an active opt-out status, have the patient sign a private contract acknowledging that Medicare will not be billed and the patient is responsible for the full fee.\n\nRecord: signed private contract in patient file",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Execute a private contract with the beneficiary"
        },
        {
          "detail": "The practice owner decides whether to pursue Medicare enrollment (ongoing administrative burden, allows routine billing), file an opt-out affidavit (allows private-contract billing with beneficiaries for two-year renewable terms), or treat this single case as an exception requiring ad hoc guidance.\n\nWhy: Enrollment and opt-out are both binding, multi-year administrative commitments — this is a practice-strategy decision, not something resolved case-by-case at the front desk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner decision: enroll, opt out, or handle as an isolated exception.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner decision: enroll, opt out, or handle as an isolated exception",
          "why": "Enrollment and opt-out are both binding, multi-year administrative commitments — this is a practice-strategy decision, not something resolved case-by-case at the front desk."
        },
        {
          "detail": "Owner's decision",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "enroll",
              "label": "Enroll as a Medicare provider"
            },
            {
              "goto": "s14",
              "id": "opt-out",
              "label": "File opt-out affidavit"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Owner's decision"
        },
        {
          "detail": "Complete and submit the CMS-855I enrollment application; retain confirmation and track the effective date.\n\nRecord: enrollment submission confirmation and effective date",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "File Medicare provider enrollment (CMS-855I)"
        },
        {
          "detail": "Complete and submit the opt-out affidavit to the Medicare Administrative Contractor; note the two-year term and renewal date.\n\nWhy: An opt-out affidavit lapses if not renewed and reverts the dentist to non-enrolled status, which blocks billing entirely until a new status is filed.\n\nRecord: opt-out affidavit filing date and renewal date",
          "id": "s14",
          "kind": "step",
          "role": "billing",
          "title": "File a Medicare opt-out affidavit",
          "why": "An opt-out affidavit lapses if not renewed and reverts the dentist to non-enrolled status, which blocks billing entirely until a new status is filed."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Medicare status decision — enroll, opt out or order-and-refer only — A Medicare beneficiary needs a medically necessary dental service or a prescription covered by Part D.",
      "title": "Medicare status decision — enroll, opt out or order-and-refer only",
      "trigger": "A Medicare beneficiary needs a medically necessary dental service or a prescription covered by Part D",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733",
          "source": "False Claims Act 31 U.S.C. §3729–3733",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "public_domain",
          "label": "OIG Provider Self-Disclosure Protocol",
          "source": "OIG Provider Self-Disclosure Protocol",
          "url": "https://oig.hhs.gov/compliance/self-disclosure-info/"
        },
        {
          "kind": "regulation",
          "label": "Medicare/Medicaid overpayment reporting and return — 60-day rule, 42 CFR 401.305",
          "repaired": {
            "action": "replace",
            "evidence": "A person who has received an overpayment must report and return the overpayment by the later of either: (i) the date which is 60 days after the date on which the overpayment was identified, or (ii) the date any corresponding cost report is due, if applicable.",
            "ticket": "PROT-017",
            "was": {
              "source": "Medicaid provider rules 42 CFR Part 455 (overpayment identification and 60-day return requirement)",
              "url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455"
            }
          },
          "source": "42 CFR 401.305 (Part 401, Subpart D) — Requirements for reporting and returning of overpayments",
          "url": "https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "fin-021",
      "kind": "operational",
      "materials": [
        "internal audit findings summary",
        "sample of affected claims with chart cross-reference",
        "legal counsel contact",
        "OIG Self-Disclosure Protocol or CMS Voluntary Self-Referral Disclosure Protocol reference",
        "corrective action plan template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "billing",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "The compliance officer reviews the audit finding and the sample of affected claims to confirm this is a systematic pattern (not an isolated error handled under routine correction) before the matter is escalated further.\n\nWhy: This protocol is for a pattern, not a single mistake — routing an isolated error into a self-disclosure track wastes legal-counsel time and can create disclosure obligations that would not otherwise attach.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms the finding before it proceeds.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms the finding before it proceeds",
          "why": "This protocol is for a pattern, not a single mistake — routing an isolated error into a self-disclosure track wastes legal-counsel time and can create disclosure obligations that would not otherwise attach."
        },
        {
          "detail": "Identify the date range, the specific error pattern (upcoding, unbundling, misdated service), the number of claims affected, and the total dollar exposure, cross-referencing each sampled claim against the clinical chart.\n\nWhy: Both legal counsel's advice and any eventual refund or disclosure filing depend on knowing precisely how large and how long-running the pattern is.\n\nRecord: audit findings summary with claim list and dollar exposure",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Quantify the scope of affected claims",
          "why": "Both legal counsel's advice and any eventual refund or disclosure filing depend on knowing precisely how large and how long-running the pattern is."
        },
        {
          "detail": "The treating dentist (or a licensed clinician reviewer) reviews the sampled affected claims against the clinical chart and confirms which code, if any, is actually supportable for each — before counsel or the owner acts on the quantified scope.\n\nWhy: The quantified dollar exposure and any eventual refund/resubmission rest on a clinical judgment about what the chart actually supports; a compliance-officer-only cross-reference is not a licensed clinical determination (CLAUDE.md #4).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed clinician confirms the corrected codes against the chart.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed clinician confirms the corrected codes against the chart",
          "why": "The quantified dollar exposure and any eventual refund/resubmission rest on a clinical judgment about what the chart actually supports; a compliance-officer-only cross-reference is not a licensed clinical determination (CLAUDE.md #4)."
        },
        {
          "detail": "Hand the audit findings summary to legal counsel for advice on self-disclosure obligations, refund mechanics, and any privilege considerations before further internal communication about the finding.\n\nWhy: A systematic billing error carries False Claims Act exposure; counsel's involvement before wider internal discussion also helps preserve privilege over the investigation.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage legal counsel before further action",
          "why": "A systematic billing error carries False Claims Act exposure; counsel's involvement before wider internal discussion also helps preserve privilege over the investigation."
        },
        {
          "detail": "Counsel's recommendation",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "disclose",
              "label": "Self-disclose through the applicable protocol and refund"
            },
            {
              "goto": "s12",
              "id": "refund-only",
              "label": "Correct and refund without formal self-disclosure filing"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Counsel's recommendation"
        },
        {
          "detail": "The practice owner reviews and approves the self-disclosure submission (e.g. OIG Self-Disclosure Protocol or the applicable state Medicaid self-audit process) prepared with counsel before it is filed.\n\nWhy: A self-disclosure filing is a formal admission with legal consequences — it goes out only with the owner's explicit, informed approval, never on staff or counsel initiative alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off on the self-disclosure filing.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off on the self-disclosure filing",
          "why": "A self-disclosure filing is a formal admission with legal consequences — it goes out only with the owner's explicit, informed approval, never on staff or counsel initiative alone."
        },
        {
          "detail": "The treating dentist (or a licensed clinician reviewer) confirms the corrected CDT codes being filed with the self-disclosure actually match what the clinical chart supports.\n\nWhy: The self-disclosure filing states corrected codes and a refund amount as fact — those corrected codes are a clinical-billing determination and never go out on owner/counsel sign-off alone (CLAUDE.md #4).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed clinician confirms corrected CDT codes before filing.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed clinician confirms corrected CDT codes before filing",
          "why": "The self-disclosure filing states corrected codes and a refund amount as fact — those corrected codes are a clinical-billing determination and never go out on owner/counsel sign-off alone (CLAUDE.md #4)."
        },
        {
          "detail": "Submit the self-disclosure per the applicable protocol, including the quantified overpayment amount and corrective action plan; issue payment per the protocol's instructions.\n\nRecord: self-disclosure filing confirmation and refund payment record",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "File the self-disclosure and calculate the refund"
        },
        {
          "detail": "Identify the root cause (staff training gap, software template error, coding misunderstanding), fix it, and document the fix so the pattern does not recur.\n\nWhy: A refund without a fix to the underlying cause invites the exact same finding on the next audit cycle.\n\nRecord: corrective action plan with root cause and fix",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Implement a corrective action plan",
          "why": "A refund without a fix to the underlying cause invites the exact same finding on the next audit cycle."
        },
        {
          "detail": "Record the final disposition (disclosed and refunded, or corrected and refunded), amounts, dates, and the corrective action plan in the compliance file.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close out the incident record"
        },
        {
          "detail": "Billing error corrected and closed",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Billing error corrected and closed"
        },
        {
          "detail": "The practice owner approves correcting and refunding the affected claims without a formal disclosure filing, per counsel's advice, before billing executes the corrections.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off on refund-only correction.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off on refund-only correction"
        },
        {
          "detail": "The treating dentist (or a licensed clinician reviewer) confirms the corrected CDT codes being resubmitted or rebilled actually match what the clinical chart supports.\n\nWhy: Resubmitting or rebilling a claim with a different code is a clinical-billing consequential step — it never goes out on an owner-level administrative approval alone (CLAUDE.md #4).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed clinician confirms corrected CDT codes before resubmission.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed clinician confirms corrected CDT codes before resubmission",
          "why": "Resubmitting or rebilling a claim with a different code is a clinical-billing consequential step — it never goes out on an owner-level administrative approval alone (CLAUDE.md #4)."
        },
        {
          "detail": "Resubmit or void and rebill each affected claim correctly; refund any resulting overpayment to the payer within the applicable return deadline (commonly 60 days from identification under federal Medicaid rules).\n\nWhy: Federal Medicaid rules treat an identified overpayment not returned within 60 days as a separate False Claims Act violation — the clock starts at discovery, not at the decision to act.\n\nRecord: corrected claims list and refund payment record",
          "id": "s14",
          "kind": "step",
          "role": "billing",
          "title": "Correct the affected claims and issue refunds",
          "why": "Federal Medicaid rules treat an identified overpayment not returned within 60 days as a separate False Claims Act violation — the clock starts at discovery, not at the decision to act."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Discovered systematic billing error — correction, refund and self-disclosure decision — An internal audit finds systematic upcoding, unbundling or misdated claims that do not match the clinical record.",
      "title": "Discovered systematic billing error — correction, refund and self-disclosure decision",
      "trigger": "An internal audit finds systematic upcoding, unbundling or misdated claims that do not match the clinical record",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "PCI DSS (open standard); card network surcharge rules published by Visa and Mastercard require advance notice to the network and acquirer, capped surcharge percentage, and clear point-of-sale disclosure",
          "source": "PCI DSS (open standard); card network surcharge rules published by Visa and Mastercard require advance notice to the network and acquirer, capped surcharge percentage, and clear point-of-sale disclosure",
          "url": "https://www.pcisecuritystandards.org/"
        },
        {
          "kind": "generic",
          "label": "State surcharge and cash-discount statutes vary — several states restrict or prohibit card surcharges; practices must confirm current state law before implementing",
          "source": "State surcharge and cash-discount statutes vary — several states restrict or prohibit card surcharges; practices must confirm current state law before implementing"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fin-022",
      "kind": "operational",
      "materials": [
        "card network surcharge/cash-discount rules (Visa, Mastercard, etc.)",
        "state law reference on surcharging (some states restrict or ban it)",
        "payment processor agreement",
        "posted pricing signage template",
        "point-of-sale system configuration access"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check current state law — some states restrict or prohibit merchant card surcharges outright, while cash-discount programs (a higher posted price with a discount for cash/debit) are more broadly permitted. Confirm which structure is legal before proceeding.\n\nWhy: State surcharge law changes periodically and a program built on last year's rule can become non-compliant without anyone changing anything at the practice.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm whether card surcharging is permitted in the practice's state",
          "why": "State surcharge law changes periodically and a program built on last year's rule can become non-compliant without anyone changing anything at the practice."
        },
        {
          "detail": "What does state law allow?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "surcharge-ok",
              "label": "Card surcharging is permitted"
            },
            {
              "goto": "s9",
              "id": "discount-only",
              "label": "Only a cash-discount structure is permitted or preferred"
            },
            {
              "goto": "s10",
              "id": "prohibited",
              "label": "Both are restricted or prohibited in this state"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "What does state law allow?"
        },
        {
          "detail": "Confirm the surcharge percentage does not exceed the network's cap, that debit cards are excluded if required, that advance notice to the card networks and acquirer is filed, and that the practice's payment processor supports compliant surcharge processing.\n\nWhy: Card network rules operate independently of state law — meeting state law without meeting network rules still exposes the practice to processor penalties or account termination.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Check card network surcharge rules",
          "why": "Card network rules operate independently of state law — meeting state law without meeting network rules still exposes the practice to processor penalties or account termination."
        },
        {
          "detail": "Post the surcharge percentage clearly at the point of entry and at checkout, and disclose it on the receipt as a separate line item.\n\nWhy: Card network rules and most state disclosure requirements both hinge on the patient seeing the fee before the transaction, not discovering it on the receipt afterward.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Design point-of-sale and pre-transaction disclosure signage",
          "why": "Card network rules and most state disclosure requirements both hinge on the patient seeing the fee before the transaction, not discovering it on the receipt afterward."
        },
        {
          "detail": "The practice owner reviews the final surcharge or cash-discount design, signage, and processor configuration before the program is activated.\n\nWhy: A pricing change that touches every patient transaction and carries state and card-network compliance obligations should not go live on staff-level discretion alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before the program goes live.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before the program goes live",
          "why": "A pricing change that touches every patient transaction and carries state and card-network compliance obligations should not go live on staff-level discretion alone."
        },
        {
          "detail": "Set up the payment terminal/software to apply the fee or discount correctly and display the required disclosure; post physical signage at the entrance and check-out counter.\n\nRecord: processor configuration change log; signage installed date",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Configure the point-of-sale system and post signage"
        },
        {
          "detail": "Log the program start date, structure, and a scheduled review date to re-confirm state law and network rules remain compliant.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the program launch and review date"
        },
        {
          "detail": "Card fee / cash-discount program compliant and live",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Card fee / cash-discount program compliant and live"
        },
        {
          "detail": "Set a standard posted price with a stated discount for cash or debit payment, so the card price is the 'regular' price rather than a fee added on top.\n\nWhy: A cash-discount structure is treated differently under many state laws than a surcharge, even though the dollar effect on the patient can be similar — the framing matters legally.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Design a cash-discount program instead",
          "why": "A cash-discount structure is treated differently under many state laws than a surcharge, even though the dollar effect on the patient can be similar — the framing matters legally."
        },
        {
          "detail": "Continue standard pricing with no fee differential by payment method.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Do not implement a surcharge or cash-discount program"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Card surcharge, convenience fee and cash-discount program compliance — The practice considers passing card fees to patients or advertising a cash price.",
      "title": "Card surcharge, convenience fee and cash-discount program compliance",
      "trigger": "The practice considers passing card fees to patients or advertising a cash price",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "IRS recordkeeping requirements for business expenses (Publication 583; Publication 463 substantiation rules — receipts/records for reimbursed expenses)",
          "source": "IRS recordkeeping requirements for business expenses (Publication 583; Publication 463 substantiation rules — receipts/records for reimbursed expenses)",
          "url": "https://www.irs.gov/publications/p583"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 20,
      "frequency": "monthly",
      "id": "fin-023",
      "kind": "operational",
      "materials": [
        "petty cash box and log",
        "reimbursement request form",
        "original receipts",
        "company card statement",
        "expense category reference list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "What triggered this cycle?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "reimbursement",
              "label": "Reimbursement request submitted"
            },
            {
              "goto": "s8",
              "id": "monthly",
              "label": "Monthly card statement reconciliation"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "What triggered this cycle?"
        },
        {
          "detail": "Have the requesting team member submit the reimbursement form with the original itemized receipt and a stated business purpose.\n\nWhy: A reimbursement without an itemized receipt and stated purpose cannot be verified or correctly categorized later.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect the reimbursement request and original receipt",
          "why": "A reimbursement without an itemized receipt and stated purpose cannot be verified or correctly categorized later."
        },
        {
          "detail": "Confirm the amount matches the receipt, the expense is a legitimate business purpose, and it is assigned to the correct category for the books.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the request against the receipt and expense category"
        },
        {
          "detail": "Is the reimbursement amount above the owner sign-off threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "below",
              "label": "Below threshold — office manager approves"
            },
            {
              "goto": "s13",
              "id": "above",
              "label": "At or above threshold"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the reimbursement amount above the owner sign-off threshold?"
        },
        {
          "detail": "Pay via petty cash box (if within the box's float amount) or by check/transfer; file the receipt and form together.\n\nRecord: reimbursement payment and filed receipt",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Issue the reimbursement payment"
        },
        {
          "detail": "If paid from the petty cash box, record the amount, date, purpose and remaining balance in the petty cash log immediately.\n\nWhy: A petty cash box with no contemporaneous log is impossible to reconcile — the log is the only record of what left the box and why.\n\nRecord: petty cash log entry",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the petty cash box transaction if applicable",
          "why": "A petty cash box with no contemporaneous log is impossible to reconcile — the log is the only record of what left the box and why."
        },
        {
          "detail": "Reimbursement processed",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Reimbursement processed"
        },
        {
          "detail": "Download or print the statement for all company cards issued to staff for the billing period.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the monthly company-card statement"
        },
        {
          "detail": "Go through every line item on the statement and confirm a receipt and stated business purpose exists for it; flag any charge missing either.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Match each charge to a receipt and business purpose"
        },
        {
          "detail": "Are any charges missing a receipt or business purpose?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "clean",
              "label": "All charges accounted for"
            },
            {
              "goto": "s14",
              "id": "flagged",
              "label": "One or more charges are unexplained"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are any charges missing a receipt or business purpose?"
        },
        {
          "detail": "Enter categorized charges into the practice's bookkeeping records and confirm the statement balance matches the payment made to the card issuer.\n\nRecord: monthly reconciliation entry",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Reconcile the statement against the books"
        },
        {
          "detail": "Monthly card reconciliation complete",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Monthly card reconciliation complete"
        },
        {
          "detail": "The practice owner reviews and approves the reimbursement before payment is issued.\n\nWhy: A fixed threshold keeps routine small reimbursements moving quickly while ensuring larger outflows get a second set of eyes.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner approval for above-threshold reimbursement.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner approval for above-threshold reimbursement",
          "why": "A fixed threshold keeps routine small reimbursements moving quickly while ensuring larger outflows get a second set of eyes."
        },
        {
          "detail": "Present flagged charges to the practice owner for review before the reconciliation is closed; the card-holding staff member is asked to explain or provide the missing receipt.\n\nWhy: An unexplained charge on a company card, left unresolved, is exactly the pattern that a later embezzlement review (fin-001) has to reconstruct after the fact — catching it monthly is far cheaper than catching it in an audit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review of unexplained company-card charges.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s14",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review of unexplained company-card charges",
          "why": "An unexplained charge on a company card, left unresolved, is exactly the pattern that a later embezzlement review (fin-001) has to reconstruct after the fact — catching it monthly is far cheaper than catching it in an audit."
        },
        {
          "detail": "Obtain the missing receipt/explanation, or if unresolved, document the finding and any corrective action (repayment, card privileges review).\n\nRecord: resolution note on flagged charge",
          "id": "s15",
          "kind": "step",
          "role": "office-manager",
          "title": "Resolve the flagged charge"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Petty cash, expense reimbursement and company-card controls — A team member submits a reimbursement, or the monthly card statement is reconciled.",
      "title": "Petty cash, expense reimbursement and company-card controls",
      "trigger": "A team member submits a reimbursement, or the monthly card statement is reconciled",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "IRS Form 8300 cash reporting 26 U.S.C. §6050I (large cash transactions this control feeds into)",
          "source": "IRS Form 8300 cash reporting 26 U.S.C. §6050I (large cash transactions this control feeds into)",
          "url": "https://www.irs.gov/businesses/small-businesses-self-employed/form-8300-and-reporting-cash-payments-of-over-10000"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 15,
      "frequency": "daily",
      "id": "fin-024",
      "kind": "operational",
      "materials": [
        "tamper-evident deposit bag",
        "deposit slip",
        "day-sheet total for reconciliation",
        "deposit log",
        "bank deposit receipt or confirmation"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Count cash and checks, complete the deposit slip, and confirm the total matches the day-sheet total for the period covered.\n\nWhy: Reconciling before sealing the bag is the last chance to catch a shortfall while the day's records are still fresh and easy to trace.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Prepare the deposit and reconcile against the day-sheet",
          "why": "Reconciling before sealing the bag is the last chance to catch a shortfall while the day's records are still fresh and easy to trace."
        },
        {
          "detail": "Does the deposit total match the day-sheet?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "match",
              "label": "Totals match"
            },
            {
              "goto": "s9",
              "id": "mismatch",
              "label": "Totals do not match"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the deposit total match the day-sheet?"
        },
        {
          "detail": "Place cash, checks and the deposit slip in a tamper-evident deposit bag, seal it, and record the bag's serial number in the deposit log.\n\nWhy: A tamper-evident seal is what makes it possible to establish, after the fact, whether the bag was opened between the office and the bank.\n\nRecord: deposit log: bag serial number, amount, date, time sealed",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Seal the deposit in a tamper-evident bag",
          "why": "A tamper-evident seal is what makes it possible to establish, after the fact, whether the bag was opened between the office and the bank."
        },
        {
          "detail": "Is the deposit transported to the bank immediately, or held until later?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "immediate",
              "label": "Transported same day"
            },
            {
              "goto": "s11",
              "id": "held",
              "label": "Held for later transport"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the deposit transported to the bank immediately, or held until later?"
        },
        {
          "detail": "Transport the sealed bag to the bank, varying route and timing day to day where practical rather than a fixed predictable schedule.\n\nWhy: A fixed, publicly observable deposit run at the same time and route every day is a known physical-security risk for cash-in-transit robbery.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Transport the deposit to the bank",
          "why": "A fixed, publicly observable deposit run at the same time and route every day is a known physical-security risk for cash-in-transit robbery."
        },
        {
          "detail": "Get a stamped or electronic deposit confirmation from the bank and file it with the deposit log entry for that date.\n\nRecord: bank deposit receipt matched to deposit log entry",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Obtain and retain the bank deposit receipt"
        },
        {
          "detail": "Confirm the amount credited by the bank matches the sealed amount recorded in the deposit log; flag any variance to the practice owner.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Reconcile the bank confirmation against the deposit log"
        },
        {
          "detail": "Deposit transported and reconciled",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Deposit transported and reconciled"
        },
        {
          "detail": "Stop and hand the discrepancy to the office manager for investigation under the end-of-day cash discrepancy protocol before the deposit is sealed and transported.\n\nWhy: A discrepancy sealed into the bag and taken to the bank is much harder to trace back to its cause than one caught at the counter.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand a mismatch to the office manager before sealing",
          "why": "A discrepancy sealed into the bag and taken to the bank is much harder to trace back to its cause than one caught at the counter."
        },
        {
          "detail": "The office manager confirms the discrepancy is investigated and either resolved or explicitly documented as unresolved before authorizing the deposit to be sealed and transported.\n\nWhy: Sealing and moving money before a known discrepancy is explained removes the office's own ability to later reconstruct where it happened.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager sign-off before an unresolved discrepancy is sealed.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager sign-off before an unresolved discrepancy is sealed",
          "why": "Sealing and moving money before a known discrepancy is explained removes the office's own ability to later reconstruct where it happened."
        },
        {
          "detail": "Place the sealed bag in a locked safe not accessible to the person who will transport it alone; log the time it was placed in the safe.\n\nWhy: Same-person, same-key custody from counting through transport removes the separation of duties that makes a deposit process auditable.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Store the sealed deposit securely until transport",
          "why": "Same-person, same-key custody from counting through transport removes the separation of duties that makes a deposit process auditable."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Bank deposit transport and cash-in-transit controls — The daily deposit is taken to the bank.",
      "title": "Bank deposit transport and cash-in-transit controls",
      "trigger": "The daily deposit is taken to the bank",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Health & Safety Code §1371.1 — health-plan overpayment-notice/refund-dispute timing only",
          "repaired": {
            "action": "reduce",
            "evidence": "The audit's own verification (via search) confirms H&S §1371.1 governs health-plan-to-provider overpayment notice, 30-day response, and interest-accrual rules — matching fin-017's subject exactly. The bundled URL (sco.ca.gov/upd_rptg.html) is the State Controller's Unclaimed Property reporting page and addresses escheatment, not any of the three protocols' subjects.",
            "ticket": "PROT-017",
            "was": {
              "source": "California overpayment recoupment limits H&S §1371.1 / Ins. Code §10123.145; Unclaimed Property Law CCP §1500 et seq.; Rosenthal Act Civ. Code §1788",
              "url": "https://www.sco.ca.gov/upd_rptg.html"
            }
          },
          "source": "Cal. Health & Safety Code §1371.1 (health-plan-to-provider overpayment notice, statutory time limits, interest accrual). Scope: fin-017 (payer overpayment notice — verification, statutory time limits, refund or dispute) only — does NOT reach fin-003 (patient demands a refund for treatment/prepayment) or fin-025 (patient bankruptcy notice), which are not overpayment-recoupment matters. Drops the Unclaimed Property Law citation and its URL (sco.ca.gov/upd_rptg.html is the State Controller's unclaimed-property page and supports none of the three protocols) and drops the Rosenthal Fair Debt Collection Act (Civ. Code §1788, which governs debt-collection conduct, not refund/overpayment mechanics).",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1371.1&lawCode=HSC"
        },
        {
          "kind": "statute",
          "label": "U.S. Bankruptcy Code automatic stay, 11 U.S.C. §362 — collection actions against the debtor and property of the estate are stayed upon filing",
          "source": "U.S. Bankruptcy Code automatic stay, 11 U.S.C. §362 — collection actions against the debtor and property of the estate are stayed upon filing",
          "url": "https://www.law.cornell.edu/uscode/text/11/362"
        },
        {
          "kind": "generic",
          "label": "Standard accounts-receivable ledger reconciliation and account-hold/freeze practice — generic functional equivalent, no single public-domain document governs a practice's own AR system controls",
          "source": "Standard accounts-receivable ledger reconciliation and account-hold/freeze practice — generic functional equivalent, no single public-domain document governs a practice's own AR system controls"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fin-025",
      "kind": "operational",
      "materials": [
        "bankruptcy notice / Notice of Bankruptcy Case Filing",
        "patient ledger",
        "proof-of-claim form (if requested)",
        "collections hold log",
        "creditor mailing list update sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Date-stamp the notice the day it arrives (mail or court e-filing alert) and record the patient's account number, case number, filing date, and the bar date for filing claims if one is stated.\n\nWhy: The automatic stay attaches the moment the case is filed, not when the practice notices it — an undated log is how a collection call happens after the stay is already in effect.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Log receipt of the notice",
          "why": "The automatic stay attaches the moment the case is filed, not when the practice notices it — an undated log is how a collection call happens after the stay is already in effect."
        },
        {
          "detail": "No collection call, statement, letter, or payment-plan reminder goes out on this account until a named person has confirmed the stay applies and instructed staff to freeze it.\n\nWhy: A statement or dunning letter sent after filing can be read as a stay violation exposing the practice to sanctions — the freeze has to be a deliberate, recorded act, not an assumption.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before any account action.",
            "role": "office-manager or compliance-officer",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "office-manager",
          "title": "Compliance sign-off before any account action",
          "why": "A statement or dunning letter sent after filing can be read as a stay violation exposing the practice to sanctions — the freeze has to be a deliberate, recorded act, not an assumption."
        },
        {
          "detail": "Mark the account 'bankruptcy hold — do not bill, do not call' so automated statement runs and recall reminders skip it; note the freeze date and case number in the account memo field.\n\nWhy: Automated billing cycles do not know about a court filing unless someone tells the software.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Freeze the account in the practice management system",
          "why": "Automated billing cycles do not know about a court filing unless someone tells the software."
        },
        {
          "detail": "Compare the balance to the practice's internal threshold for whether pursuing a formal claim in the case is worth the administrative cost.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "o1",
              "label": "Below threshold — do not file a claim, write off if discharged"
            },
            {
              "goto": "s11",
              "id": "o2",
              "label": "Above threshold — prepare and file a proof of claim"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the balance owed under a threshold that does not warrant filing a proof of claim?"
        },
        {
          "detail": "Write the reason for not filing a claim, the dollar amount, and the decision-maker's name into the account memo.\n\nRecord: Reason for not filing a claim, dollar amount, and the decision-maker's name are written into the account memo.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Note no-claim decision on the account"
        },
        {
          "detail": "Hand the case file to the practice's outside legal or accounting advisor when the patient disputes the balance, files an objection, or the practice intends to seek relief from the stay.\n\nWhy: Routine notices can be handled in-house; contested claims carry legal risk that belongs with a licensed advisor.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Route to outside counsel or an accountant if the case is contested or complex",
          "why": "Routine notices can be handled in-house; contested claims carry legal risk that belongs with a licensed advisor."
        },
        {
          "detail": "Hold the account frozen until a discharge order, dismissal notice, or plan confirmation arrives from the court; check the case docket periodically if counsel is not tracking it directly. Duration is a placeholder (~90 days) — actual wait varies by case and can run considerably longer.",
          "id": "s7",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 7776000,
          "title": "Wait for case resolution or discharge notice"
        },
        {
          "detail": "What did the court order?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "o3",
              "label": "Debt discharged — write off the balance"
            },
            {
              "goto": "s12",
              "id": "o4",
              "label": "Case dismissed without discharge — resume normal billing"
            },
            {
              "goto": "s13",
              "id": "o5",
              "label": "Repayment plan confirmed — bill only per the plan terms"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "What did the court order?"
        },
        {
          "detail": "Adjust the account to zero, code the write-off as 'bankruptcy discharge', and file the discharge order in the account record.\n\nWhy: Attempting to collect a discharged debt is itself a stay/discharge-injunction violation.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Write off the discharged balance",
          "why": "Attempting to collect a discharged debt is itself a stay/discharge-injunction violation."
        },
        {
          "detail": "Case closed on the account",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Case closed on the account"
        },
        {
          "detail": "Assemble the ledger showing dates of service, amounts owed, and any supporting statements; complete the proof-of-claim form with the balance as of the filing date and submit by the bar date.\n\nWhy: A late-filed claim can be disallowed even if the debt is otherwise valid.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Prepare the proof of claim",
          "why": "A late-filed claim can be disallowed even if the debt is otherwise valid."
        },
        {
          "detail": "Lift the freeze, resend any statements missed during the hold period, and note the dismissal date on the account.",
          "id": "s12",
          "kind": "step",
          "role": "billing",
          "title": "Remove the account hold and resume normal billing"
        },
        {
          "detail": "Set up billing to match exactly what the confirmed repayment plan allows — no additional charges, fees, or reminders outside the plan terms.\n\nWhy: A confirmed plan supersedes normal billing terms while it is in effect.",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "Bill according to the confirmed plan only",
          "why": "A confirmed plan supersedes normal billing terms while it is in effect."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Patient bankruptcy notice received — A bankruptcy court notice names the practice as a creditor for a patient balance.",
      "title": "Patient bankruptcy notice received",
      "trigger": "A bankruptcy court notice names the practice as a creditor for a patient balance",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "State seller's-permit and sales-and-use-tax registration requirements (generic across states; verify the practice's own state department of revenue) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "State seller's-permit and sales-and-use-tax registration requirements (generic across states; verify the practice's own state department of revenue)"
          },
          "source": "State seller's-permit and sales-and-use-tax registration requirements (generic across states; verify the practice's own state department of revenue) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "IRS Form 8300 large-cash reporting for cash payments over $10,000, 26 U.S.C. §6050I",
          "source": "IRS Form 8300 large-cash reporting for cash payments over $10,000, 26 U.S.C. §6050I",
          "url": "https://www.irs.gov/businesses/small-businesses-self-employed/form-8300-and-reporting-cash-payments-of-over-10000"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "fin-026",
      "kind": "operational",
      "materials": [
        "retail sales log / point-of-sale report",
        "sales tax permit / seller's permit number",
        "state sales-tax return form or portal login",
        "inventory count sheet",
        "product price list with tax status noted"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "billing",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Register for a seller's/sales-tax permit with the state department of revenue before the first over-the-counter sale of a whitening kit, electric brush, mouthguard, or similar retail item.\n\nWhy: Selling a taxable product without a permit is a compliance gap that compounds every month it goes uncorrected.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm the practice holds a seller's permit before selling any retail product",
          "why": "Selling a taxable product without a permit is a compliance gap that compounds every month it goes uncorrected."
        },
        {
          "detail": "For each SKU record: item name, cost, retail price, whether it is taxable under state rules, and the tax rate applied at the point of sale.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Set up each retail item correctly in the point-of-sale system"
        },
        {
          "detail": "Ring the sale through the point-of-sale system (not the clinical charting system) so tax is calculated and captured automatically; issue the patient a receipt showing the taxable amount separately.\n\nWhy: Mixing a retail sale into a clinical charge record makes the tax owed impossible to reconstruct later.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Record every retail sale at the point of sale",
          "why": "Mixing a retail sale into a clinical charge record makes the tax owed impossible to reconstruct later."
        },
        {
          "detail": "Physically count remaining stock of each retail item and compare it to what the point-of-sale system says should be on the shelf; note any shortage or overage.\n\nWhy: Shrinkage that goes unnoticed for months is much harder to trace to a cause.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Do a monthly inventory count",
          "why": "Shrinkage that goes unnoticed for months is much harder to trace to a cause."
        },
        {
          "detail": "Does the physical count match the system count?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "o1",
              "label": "Counts match — proceed to tax reconciliation"
            },
            {
              "goto": "s11",
              "id": "o2",
              "label": "Discrepancy found — investigate before closing the month"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the physical count match the system count?"
        },
        {
          "detail": "Pull the month's point-of-sale report and confirm the total sales-tax-collected line matches what will be remitted on the return.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Reconcile tax collected against the point-of-sale report"
        },
        {
          "detail": "Is a return due this cycle (monthly/quarterly per the state's assigned frequency)?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "o3",
              "label": "Yes — file and remit now"
            },
            {
              "goto": "s12",
              "id": "o4",
              "label": "No — hold the reconciled total for the next filing cycle"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a return due this cycle (monthly/quarterly per the state's assigned frequency)?"
        },
        {
          "detail": "Submit the return through the state's portal or form by the due date, remit the tax collected, and save the confirmation.\n\nWhy: Late filing typically carries a penalty and interest even if the tax amount itself is correct.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "File the sales-tax return and remit payment",
          "why": "Late filing typically carries a penalty and interest even if the tax amount itself is correct."
        },
        {
          "detail": "File the point-of-sale report, inventory count sheet, discrepancy notes, and the filed return together under the month.\n\nRecord: Point-of-sale report, inventory count sheet, discrepancy notes, and the filed return (or carry-forward note) are filed together under the month.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "File the month's retail package"
        },
        {
          "detail": "Monthly retail cycle closed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Monthly retail cycle closed"
        },
        {
          "detail": "Write down the item, expected count, actual count, and the likely cause; escalate anything unexplained above a set dollar threshold to the practice owner.\n\nRecord: Item, expected count, actual count, and a note on the likely cause (breakage, sample giveaway not logged, register error, or theft) are written to the inventory log; anything unexplained above a set dollar threshold is escalated to the practice owner.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log and investigate the discrepancy"
        },
        {
          "detail": "File the month's collected tax total and reconciliation notes for the upcoming filing cycle.\n\nRecord: Month's collected tax total and reconciliation notes are filed for the upcoming filing cycle.",
          "id": "s12",
          "kind": "step",
          "role": "billing",
          "title": "Carry the reconciled total forward"
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Retail product sales (whitening kits, brushes): sales tax and inventory — The practice sells products over the counter, or a sales-tax registration or return is due.",
      "title": "Retail product sales (whitening kits, brushes): sales tax and inventory",
      "trigger": "The practice sells products over the counter, or a sales-tax registration or return is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ERISA reporting and disclosure requirements, 29 U.S.C. §1021 et seq.; Form 5500 series filed via the EFAST2 electronic filing system",
          "source": "ERISA reporting and disclosure requirements, 29 U.S.C. §1021 et seq.; Form 5500 series filed via the EFAST2 electronic filing system",
          "url": "https://www.efast.dol.gov/"
        },
        {
          "kind": "statute",
          "label": "Internal Revenue Code qualified plan nondiscrimination and top-heavy testing, 26 U.S.C. §401(k), §401(m), §416",
          "source": "Internal Revenue Code qualified plan nondiscrimination and top-heavy testing, 26 U.S.C. §401(k), §401(m), §416",
          "url": "https://www.irs.gov/retirement-plans/plan-sponsor/retirement-plan-forms-and-publications"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "fin-027",
      "kind": "operational",
      "materials": [
        "retirement plan document (SIMPLE/401(k)/cash-balance)",
        "employee census (eligibility dates, compensation, deferral elections)",
        "third-party administrator (TPA) contact and portal",
        "Form 5500 series filing (via TPA or EFAST2 electronic system)",
        "participant notice templates (safe harbor, QDIA, fee disclosure as applicable)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Compile each eligible employee's hire date, plan-eligibility date, compensation for the plan year, and deferral elections; send it to the third-party administrator (TPA) or plan recordkeeper.\n\nWhy: Testing and the Form 5500 both run off this census — an incomplete or late census delays everything downstream.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Pull the annual employee census",
          "why": "Testing and the Form 5500 both run off this census — an incomplete or late census delays everything downstream."
        },
        {
          "detail": "Did a new employee become eligible during the year?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "No new eligible employees — proceed to testing"
            },
            {
              "goto": "s10",
              "id": "o2",
              "label": "Yes — issue an eligibility notice before testing"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Did a new employee become eligible during the year?"
        },
        {
          "detail": "Route the completed census and prior-year plan documents to the licensed third-party administrator or plan actuary to run actual-deferral-percentage / actual-contribution-percentage nondiscrimination testing and top-heavy determination for the plan year.\n\nWhy: This testing requires specialized calculation the practice should not attempt in-house; a licensed administrator's sign-off is the record of correctness.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hand the census to the TPA for nondiscrimination and top-heavy testing",
          "why": "This testing requires specialized calculation the practice should not attempt in-house; a licensed administrator's sign-off is the record of correctness."
        },
        {
          "detail": "Do not make corrective distributions, additional contributions, or plan amendments until the TPA's written test results and recommended correction (if any) are received and reviewed.\n\nWhy: Acting on a guess about which correction method applies can itself create a new compliance failure; the administrator's determination is the authoritative basis for action.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on test results before any corrective action.",
            "role": "third-party administrator or plan actuary",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Licensed sign-off on test results before any corrective action",
          "why": "Acting on a guess about which correction method applies can itself create a new compliance failure; the administrator's determination is the authoritative basis for action."
        },
        {
          "detail": "Did the plan pass nondiscrimination and top-heavy testing?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "o3",
              "label": "Passed — proceed to annual filing"
            },
            {
              "goto": "s11",
              "id": "o4",
              "label": "Failed — apply the administrator's recommended correction"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Did the plan pass nondiscrimination and top-heavy testing?"
        },
        {
          "detail": "Complete the appropriate Form 5500 variant (5500, 5500-SF, or 5500-EZ depending on plan type and size) through the TPA or directly via the EFAST2 electronic filing system, by the deadline (the last day of the 7th month after plan year end, or the extended deadline on Form 5558).\n\nWhy: Late Form 5500 filings carry substantial per-day penalties under both DOL and IRS programs.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Prepare and file the Form 5500 series return",
          "why": "Late Form 5500 filings carry substantial per-day penalties under both DOL and IRS programs."
        },
        {
          "detail": "Send any required annual notices — safe harbor, qualified default investment alternative (QDIA), and fee disclosure — to all participants within their statutory windows.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Distribute required participant notices"
        },
        {
          "detail": "File the census, test results, correction documentation (if any), filed Form 5500 confirmation, and notice-distribution log together under the plan year.\n\nRecord: Census, test results, correction documentation (if any), filed Form 5500 confirmation, and notice-distribution log are filed together under the plan year.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "File the year's retirement-plan administration package"
        },
        {
          "detail": "Annual retirement plan administration cycle closed",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Annual retirement plan administration cycle closed"
        },
        {
          "detail": "Provide the summary plan description and enrollment materials within the plan's stated notice window after the employee becomes eligible.\n\nWhy: Missing an eligibility notice is a common, avoidable compliance failure that a TPA will flag at testing time anyway — catching it early avoids a corrective contribution later.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Send the new employee an eligibility and enrollment notice",
          "why": "Missing an eligibility notice is a common, avoidable compliance failure that a TPA will flag at testing time anyway — catching it early avoids a corrective contribution later."
        },
        {
          "detail": "Execute the TPA-recommended fix (e.g., corrective distribution to highly compensated employees, or additional employer contribution) by the deadline the administrator specifies.\n\nWhy: Corrections carry their own deadlines separate from the Form 5500 filing deadline — missing one converts a fixable issue into a plan-disqualification risk.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Apply the recommended correction within the statutory correction window",
          "why": "Corrections carry their own deadlines separate from the Form 5500 filing deadline — missing one converts a fixable issue into a plan-disqualification risk."
        }
      ],
      "subclass": "payer-compliance-financial-incidents-and-payment-security",
      "summary": "Retirement plan annual administration (testing, Form 5500, participant notices) — The plan year ends, or a new employee becomes eligible.",
      "title": "Retirement plan annual administration (testing, Form 5500, participant notices)",
      "trigger": "The plan year ends, or a new employee becomes eligible",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plans"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fuf-001",
      "kind": "operational",
      "materials": [
        "flashlights or headlamps",
        "battery or backup-power handpiece if available",
        "utility provider outage-report number",
        "generator or UPS documentation if installed",
        "patient schedule printout or offline copy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "assistant",
        "front-desk",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check hallway lights and a neighboring suite if accessible; call the building manager or utility outage line. Note whether backup power (UPS/generator) is running.\n\nWhy: Scope determines whether this is a five-minute blip or an all-day closure, which changes every downstream decision.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Determine whether the outage is building-wide or suite-only",
          "why": "Scope determines whether this is a five-minute blip or an all-day closure, which changes every downstream decision."
        },
        {
          "detail": "For each chair in use: is the patient stable and not mid-procedure with a rotary instrument in the mouth? Is the chair stuck in a reclined position? Is suction still working?",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Check every occupied operatory for patient and equipment safety"
        },
        {
          "detail": "The treating dentist, not front-of-house staff, decides whether to continue a step without full lighting/suction/handpiece power — never continue by default.\n\nWhy: A power-loss stop-or-continue call has clinical safety consequences and must be a licensed decision, not an operational one.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating dentist signs off before any in-progress procedure is stopped or continued without full power.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating dentist signs off before any in-progress procedure is stopped or continued without full power",
          "why": "A power-loss stop-or-continue call has clinical safety consequences and must be a licensed decision, not an operational one."
        },
        {
          "detail": "Weigh what stage the procedure is at and whether stopping is safer than continuing without full lighting, suction or handpiece power.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "stop-safe",
              "label": "Stop at a safe stopping point, hand-instrument or temporize as needed"
            },
            {
              "goto": "s5",
              "id": "continue-critical",
              "label": "Continue only if stopping mid-step is clinically unsafe (e.g. an open pulp)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide stop-or-continue for each in-progress procedure"
        },
        {
          "detail": "Locate the chair's manual-release lever (consult the chair's operator manual location on file) and bring the patient upright by hand.\n\nWhy: A patient should never be left reclined and immobile during a power loss.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Manually release the chair if it is stuck reclined",
          "why": "A patient should never be left reclined and immobile during a power loss."
        },
        {
          "detail": "Explain briefly that the office lost power, staff are checking the cause, and someone will update them within a few minutes. Offer water and a seat near a window for light.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Reassure patients in the waiting room and in chairs"
        },
        {
          "detail": "Use the posted utility outage number; ask for an estimated restoration window and a reference/ticket number.\n\nRecord: outage report timestamp, utility ticket number, estimated restoration time",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Call the utility provider's outage line and log the estimated restoration time"
        },
        {
          "detail": "If restoration is estimated under 30 minutes, hold the schedule; if longer or unknown, begin rescheduling remaining appointments.",
          "forks": [
            {
              "advised": false,
              "goto": "s9",
              "id": "hold",
              "label": "Hold schedule, restoration expected soon"
            },
            {
              "advised": true,
              "goto": "s9",
              "id": "reschedule-day",
              "label": "Begin rescheduling the rest of the day's patients"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide whether to reschedule the remaining day"
        },
        {
          "detail": "Call or text patients not yet checked in; offer the next available slot. Use the offline schedule copy if the practice-management system is down.\n\nWhy: Prevents patients from arriving at a closed or dark office.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify remaining scheduled patients before they arrive",
          "why": "Prevents patients from arriving at a closed or dark office."
        },
        {
          "detail": "Confirm the practice-management system boots without data corruption and the autoclave completes a normal startup cycle before resuming sterilization.\n\nWhy: A dirty power restoration can corrupt records or leave sterilization equipment in an unknown state.",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "When power returns, verify computers, x-ray sensors and the sterilizer power-cycle cleanly",
          "why": "A dirty power restoration can corrupt records or leave sterilization equipment in an unknown state."
        },
        {
          "detail": "Record start/end time, scope, patients affected, procedures stopped vs completed, and any equipment issue found on restoration, in the facility incident log.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Outage closed out",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Outage closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Power outage during clinic hours — The lights, chairs, compressor and computers go dark with patients in the operatories.",
      "title": "Power outage during clinic hours",
      "trigger": "The lights, chairs, compressor and computers go dark with patients in the operatories",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — dental unit waterlines",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — dental unit waterlines",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "public_domain",
          "label": "EPA Boil Water Advisory guidance",
          "source": "EPA Boil Water Advisory guidance",
          "url": "https://www.epa.gov/dwreginfo/boil-water-advisory"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fuf-002",
      "kind": "operational",
      "materials": [
        "bottled or distilled water for handwashing and instrument rinsing",
        "waterline shock/disinfection log",
        "municipal advisory notice or hotline number",
        "sterilization indicator strips"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "sterilization-tech",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check for a formal municipal boil-water or do-not-use advisory versus a simple pressure/outage issue; note the affected area and expected duration from the utility's published notice.\n\nWhy: A boil-water advisory has different clinical implications than a plain water-loss outage — it means the water itself may be unsafe, not just unavailable.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the scope and nature of the water event",
          "why": "A boil-water advisory has different clinical implications than a plain water-loss outage — it means the water itself may be unsafe, not just unavailable."
        },
        {
          "detail": "Per CDC dental unit waterline guidance, discontinue use of handpieces, air-water syringes and ultrasonic scalers connected to municipal water; do not use tap water for rinsing patients' mouths or hand instruments during an advisory.\n\nWhy: Licensed clinical sign-off is required before altering standard infection-control practice mid-day.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop use of dental unit waterlines and tap water for patient care.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Stop use of dental unit waterlines and tap water for patient care",
          "why": "Licensed clinical sign-off is required before altering standard infection-control practice mid-day."
        },
        {
          "detail": "For a patient already in the chair, decide whether the remaining steps can be completed with bottled/distilled water and hand instruments, or must be deferred.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "convert-bottled",
              "label": "Complete using bottled/distilled water and non-waterline instruments only"
            },
            {
              "goto": "s4",
              "id": "defer",
              "label": "Defer remaining steps and reschedule"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether to complete, defer or convert in-progress procedures"
        },
        {
          "detail": "Check the sterilizer manufacturer's water-source requirement; use distilled water for any reservoir fill and continue running biological/chemical indicators per routine.\n\nWhy: Sterilization must not stop, but tap water quality is the variable in question.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Switch sterilization processing to bottled/distilled water where the autoclave requires a water fill",
          "why": "Sterilization must not stop, but tap water quality is the variable in question."
        },
        {
          "detail": "Call remaining same-day patients whose procedures cannot be converted to bottled-water-only care; offer rebooking.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Pause new patient check-ins requiring water-dependent procedures and begin outreach"
        },
        {
          "detail": "Monitor the utility's advisory page or hotline; boil-water advisories commonly run 24–72 hours pending clearance sampling.",
          "id": "s6",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 259200,
          "title": "Wait for the municipal all-clear or advisory lift notice"
        },
        {
          "detail": "Run the office's waterline shock/disinfection procedure and verify with the waterline testing kit before returning to municipal-water-fed handpieces.\n\nWhy: Even after the municipal advisory lifts, waterlines that sat stagnant or ran contaminated water need their own clearance step.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Shock/disinfect dental unit waterlines per the waterline treatment system's protocol before resuming normal use",
          "why": "Even after the municipal advisory lifts, waterlines that sat stagnant or ran contaminated water need their own clearance step."
        },
        {
          "detail": "Record advisory start/end, procedures deferred or converted, waterline shock date and test result, in the facility incident log.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident and clearance results"
        },
        {
          "detail": "Water event closed out",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Water event closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Water main failure or boil-water advisory — Municipal water stops, pressure drops, or the utility issues a boil-water or do-not-use advisory.",
      "title": "Water main failure or boil-water advisory",
      "trigger": "Municipal water stops, pressure drops, or the utility issues a boil-water or do-not-use advisory",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — dental unit air/water systems",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — dental unit air/water systems",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "generic",
          "label": "Generic facility equipment-failure response, since no public standard governs compressor brand or model service steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic facility equipment-failure response, since no public standard governs compressor brand or model service steps"
          },
          "source": "Generic facility equipment-failure response, since no public standard governs compressor brand or model service steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "fuf-003",
      "kind": "operational",
      "materials": [
        "compressor service contact",
        "portable/backup compressor if available",
        "hand instruments as a fallback"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager",
        "dentist",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Test a second operatory's air-water syringe; if pressure is also low, this is a compressor-level failure rather than a single hose or handpiece problem.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm loss of air pressure at more than one handpiece or syringe"
        },
        {
          "detail": "Check the compressor room for tripped breakers, low tank pressure, or an audible alarm; note which operatories draw from the affected line.",
          "forks": [
            {
              "advised": false,
              "goto": "s3",
              "id": "all-down",
              "label": "All operatories affected"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "partial-down",
              "label": "Only some operatories affected"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Determine whether all operatories or only some share the failed line"
        },
        {
          "detail": "Tell each dentist which chairs have lost air pressure so they can decide how to proceed with any patient currently in that chair.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the treating dentist(s) of the affected chairs"
        },
        {
          "detail": "Weigh whether the remaining steps can be completed with hand instruments or must wait for a working chair.\n\nWhy: Compressor loss (no rotary handpiece power) is treated as lower acute risk than suction loss (aerosol/splash exposure, fuf-004) or vacuum failure, so this decision is left to the treating dentist's clinical judgment without a preceding licensed_signoff gate; escalate to a formal gate if a given case involves an open pulp, active bleeding, or another elevated-risk circumstance.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "hand-instruments",
              "label": "Finish with hand instruments where clinically appropriate"
            },
            {
              "goto": "s5",
              "id": "move-patient",
              "label": "Move the patient to a working operatory"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide how to proceed with a patient mid-procedure in an affected chair",
          "why": "Compressor loss (no rotary handpiece power) is treated as lower acute risk than suction loss (aerosol/splash exposure, fuf-004) or vacuum failure, so this decision is left to the treating dentist's clinical judgment without a preceding licensed_signoff gate; escalate to a formal gate if a given case involves an open pulp, active bleeding, or another elevated-risk circumstance."
        },
        {
          "detail": "Consolidate remaining appointments into any chair still receiving air pressure; adjust appointment order if a working chair is needed for a longer procedure.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Reroute the remaining day's schedule to working operatories"
        },
        {
          "detail": "Report the failure mode (no pressure, tripped breaker, audible alarm) and request an on-site or remote diagnostic appointment.\n\nRecord: service ticket number and estimated repair time",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Call the compressor's service or maintenance contact"
        },
        {
          "detail": "Record failure time, operatories affected, patients rerouted, and repair ticket number in the facility incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Compressor failure closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Compressor failure closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Air compressor failure — Handpieces and air-water syringes lose pressure, or the compressor alarms or trips.",
      "title": "Air compressor failure",
      "trigger": "Handpieces and air-water syringes lose pressure, or the compressor alarms or trips",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — aerosol and splash exposure control relevance",
          "source": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — aerosol and splash exposure control relevance",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol6/xml/CFR-2024-title29-vol6-sec1910-1030.xml"
        },
        {
          "kind": "generic",
          "label": "Generic facility equipment-failure response, since no public standard governs vacuum-system brand or model service steps — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic facility equipment-failure response, since no public standard governs vacuum-system brand or model service steps"
          },
          "source": "Generic facility equipment-failure response, since no public standard governs vacuum-system brand or model service steps — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "fuf-004",
      "kind": "operational",
      "materials": [
        "portable saliva ejector or backup suction unit if available",
        "service contact for the central vacuum system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager",
        "dentist",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Test the high-volume evacuator (HVE) and saliva ejector separately; note whether the loss is in one operatory or system-wide.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm suction is weak or absent at the operatory"
        },
        {
          "detail": "Do not continue a procedure that generates aerosols (handpiece use, ultrasonic scaling) without adequate evacuation; pause and reassess.\n\nWhy: Reduced suction increases aerosol and splash exposure risk for the patient and team — this requires the treating dentist's judgment before continuing.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop any aerosol-generating step until suction is restored or an alternative is in place.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Stop any aerosol-generating step until suction is restored or an alternative is in place",
          "why": "Reduced suction increases aerosol and splash exposure risk for the patient and team — this requires the treating dentist's judgment before continuing."
        },
        {
          "detail": "If a portable or backup suction unit is available and provides adequate evacuation, the procedure may continue; otherwise stop at a safe point.",
          "forks": [
            {
              "advised": false,
              "goto": "s4",
              "id": "portable-ok",
              "label": "Continue using portable/backup suction"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "stop-safe",
              "label": "Stop at a safe point and reschedule the remainder"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether a portable suction unit makes it safe to continue"
        },
        {
          "detail": "Move remaining aerosol-generating appointments to a working operatory if available, or reschedule.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Reroute or reschedule affected appointments"
        },
        {
          "detail": "Report the failure and request diagnostic service; note whether the system uses a shared motor across operatories.\n\nRecord: service ticket number and estimated repair time",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Call the vacuum system's service contact"
        },
        {
          "detail": "Record failure time, operatories affected, procedures paused, and repair ticket number in the facility incident log.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Suction failure closed out",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Suction failure closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Central vacuum or suction failure — High-volume evacuation weakens or stops in one or all operatories.",
      "title": "Central vacuum or suction failure",
      "trigger": "High-volume evacuation weakens or stops in one or all operatories",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA General Duty Clause 29 U.S.C. §654 — slip/electrical hazard relevance",
          "source": "OSHA General Duty Clause 29 U.S.C. §654 — slip/electrical hazard relevance"
        },
        {
          "kind": "generic",
          "label": "Generic facility water-damage response, since no public dental-specific standard governs flood cleanup steps",
          "source": "Generic facility water-damage response, since no public dental-specific standard governs flood cleanup steps"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fuf-005",
      "kind": "operational",
      "materials": [
        "towels, mops, wet-vac",
        "buckets or containment barriers",
        "tarps to cover equipment and records",
        "plumber or restoration vendor contact",
        "insurance carrier claim line"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "practice-owner",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "If water is pooling near an electrical outlet, powered equipment, or a light fixture, shut off the breaker for that area at the panel before staff step near it; do not touch a wet outlet or cord.\n\nWhy: Water and live electricity together is an electrocution risk that outranks every other concern in the first minute.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Cut power to any circuit or outlet near standing water before anyone approaches.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Cut power to any circuit or outlet near standing water before anyone approaches",
          "why": "Water and live electricity together is an electrocution risk that outranks every other concern in the first minute."
        },
        {
          "detail": "Clear the immediate area of standing or dripping water; reseat any patient in that chair to another operatory if in use.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Move patients and staff away from the affected area"
        },
        {
          "detail": "Locate the nearest shutoff valve for the affected fixture or the building's main shutoff if the source is unclear.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Shut off the water source if the leak is from a burst pipe or fixture"
        },
        {
          "detail": "Move paper charts, boxes, and portable equipment away from the leak; cover fixed equipment with tarps or plastic sheeting.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Protect paper records and equipment in the path of water"
        },
        {
          "detail": "Use towels, mops or a wet-vac to remove standing water and reduce spread to unaffected rooms.",
          "id": "s5",
          "kind": "step",
          "role": "all-staff",
          "title": "Contain and remove standing water"
        },
        {
          "detail": "Report the source and extent of the leak; request an emergency service window.\n\nRecord: vendor name, arrival window",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Call a plumber or restoration vendor"
        },
        {
          "detail": "Weigh whether the electrical and water hazard is contained enough to keep unaffected operatories running.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "partial-continue",
              "label": "Continue in unaffected operatories, close only the affected room"
            },
            {
              "goto": "s8",
              "id": "full-close",
              "label": "Close the office for the remainder of the day"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to close the affected area, close the office, or continue in unaffected rooms"
        },
        {
          "detail": "Call the property insurance claim line and photograph affected areas, equipment and records before cleanup removes the evidence.\n\nRecord: claim number, photo log",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the insurance carrier and document damage with photos"
        },
        {
          "detail": "Record discovery time, source, area affected, actions taken, vendor and insurance contact in the facility incident log.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Flood/leak event closed out",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Flood/leak event closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Flood, burst pipe or ceiling leak — Water is pooling on the floor or dripping from the ceiling near equipment, records or electrical outlets.",
      "title": "Flood, burst pipe or ceiling leak",
      "trigger": "Water is pooling on the floor or dripping from the ceiling near equipment, records or electrical outlets",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §3396 (Heat Illness Prevention in Indoor Places of Employment) and §5142 (ventilation)",
          "repaired": {
            "action": "replace",
            "evidence": "3396. Heat Illness Prevention in Indoor Places of Employment. ... This standard applies to most workplaces where the indoor temperature reaches 82°F and establishes required safety measures for indoor workplaces to prevent worker exposure to risk of heat illness. Covered employers [must] establish, implement, and maintain an Indoor Heat Illness Prevention Plan.",
            "ticket": "PROT-017",
            "was": {
              "source": "Cal/OSHA Title 8 §3395 (heat illness prevention) and §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Cal/OSHA Title 8 §3396",
          "url": "https://www.dir.ca.gov/title8/3396.html"
        },
        {
          "kind": "generic",
          "label": "Generic facility temperature-response, since indoor comfort thresholds vary by jurisdiction and building type",
          "source": "Generic facility temperature-response, since indoor comfort thresholds vary by jurisdiction and building type"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fuf-006",
      "kind": "operational",
      "materials": [
        "portable fans or space heaters as a stopgap",
        "thermometer",
        "HVAC service contact"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "front-desk",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Use a thermometer to check operatory and reception temperature; adjust the thermostat and listen for the system to respond.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Measure indoor temperature and confirm HVAC is not responding to the thermostat"
        },
        {
          "detail": "Offer water, open exterior doors briefly if safe, or bring in portable fans/heaters as a stopgap for waiting patients.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer immediate comfort measures"
        },
        {
          "detail": "Weigh patient and staff heat or cold stress against the HVAC vendor's estimated repair time.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "continue-mitigated",
              "label": "Continue with fans/heaters and shortened chair time as needed"
            },
            {
              "goto": "s4",
              "id": "reschedule-remaining",
              "label": "Reschedule the remaining day's appointments"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether the temperature is extreme enough to shorten the day"
        },
        {
          "detail": "Report the failure mode and request an emergency service window.\n\nRecord: service ticket number and estimated repair time",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Call the HVAC service contact"
        },
        {
          "detail": "Record temperature readings, mitigation steps, appointments affected, and repair ticket number in the facility incident log.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "HVAC event closed out",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "HVAC event closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "HVAC failure with extreme indoor temperature — Heating or cooling fails and operatory temperature climbs above or drops below a safe working range.",
      "title": "HVAC failure with extreme indoor temperature",
      "trigger": "Heating or cooling fails and operatory temperature climbs above or drops below a safe working range",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "State elevator safety code and local building/fire code — trapped-elevator response only",
          "repaired": {
            "action": "reduce",
            "evidence": "Elevator entrapment response (notify building management/elevator maintenance contractor, keep occupants calm, do not attempt self-extraction) is the subject matter state elevator safety codes and local building/fire codes actually regulate; alarm-monitoring calls, exterior vandalism, a restraining-order subject's appearance, and parking-lot personnel safety are security/HR incident types with no code provision cited or found to govern them.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic)",
              "url": null
            }
          },
          "source": "State elevator safety code and local building/fire code. Scope: fuf-007 (patient or staff trapped in the building elevator) only — does NOT reach fuf-017 (after-hours alarm/monitoring call), fuf-018 (vandalism/graffiti/property damage), fuf-023 (banned individual/restraining-order subject appears), or fuf-024 (staff parking-lot safety after dark), which are security/personnel-safety matters with no elevator, building, or fire-code content."
        },
        {
          "kind": "public_domain",
          "label": "911 public emergency dispatch",
          "source": "911 public emergency dispatch"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "fuf-007",
      "kind": "operational",
      "materials": [
        "building management emergency contact",
        "elevator emergency phone or intercom number",
        "911"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "If the person reports chest pain, panic, breathing difficulty, or any medical concern through the intercom, call 911 right away — do not wait for building management first.\n\nWhy: Entrapment can escalate quickly for someone with an underlying medical condition or anxiety; EMS response takes priority over building maintenance.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 immediately if the trapped person shows any distress, medical condition, or panic.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 immediately if the trapped person shows any distress, medical condition, or panic",
          "why": "Entrapment can escalate quickly for someone with an underlying medical condition or anxiety; EMS response takes priority over building maintenance."
        },
        {
          "detail": "Use the posted building management emergency contact or the elevator's own emergency phone/intercom number to report the entrapment and location.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Call building management or the elevator emergency line"
        },
        {
          "detail": "Reassure them help is on the way; do not attempt to force the doors open or assist extraction yourself.\n\nWhy: Untrained attempts to force elevator doors can cause a fall or crush injury.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Stay in verbal contact with the trapped person until help arrives",
          "why": "Untrained attempts to force elevator doors can cause a fall or crush injury."
        },
        {
          "detail": "If the trapped person is a scheduled patient, let the treating dentist and front desk know the appointment will be delayed and update the schedule.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the treating dentist and reception of the delay"
        },
        {
          "detail": "Continue monitoring until the trapped person is safely released.",
          "id": "s5",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1200,
          "title": "Wait for EMS or building maintenance to complete extraction"
        },
        {
          "detail": "Ask if they want a moment before their appointment or would prefer to reschedule; offer water and a seat.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Check on the released person and offer to reschedule or proceed with the appointment"
        },
        {
          "detail": "Record time trapped, time released, who was called, and any medical evaluation, in the facility incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Entrapment incident closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Entrapment incident closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Patient or staff trapped in the building elevator — Someone is stuck in the elevator on the way to or from the office.",
      "title": "Patient or staff trapped in the building elevator",
      "trigger": "Someone is stuck in the elevator on the way to or from the office",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilization area integrity",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilization area integrity",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "generic",
          "label": "Local health department food/facility pest-control code (generic) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Local health department food/facility pest-control code (generic)"
          },
          "source": "Local health department food/facility pest-control code (generic) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fuf-008",
      "kind": "operational",
      "materials": [
        "pest control vendor contact",
        "sealed containers for sterile supplies",
        "cleaning and disinfecting supplies"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "sterilization-tech",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Close off the room or storage area where the pest was seen; do not allow staff to retrieve supplies from that area until assessed.\n\nWhy: Pest activity near sterile supplies can compromise the sterility of packaged instruments and materials.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Isolate the affected area from patient traffic and sterile supply areas",
          "why": "Pest activity near sterile supplies can compromise the sterility of packaged instruments and materials."
        },
        {
          "detail": "Any packaged sterile instrument, gauze, or supply with visible contact, droppings, or damaged packaging must be discarded and not used on a patient.\n\nWhy: A licensed clinical judgment call on whether compromised supply integrity is safe to use — never assumed safe by default.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Assess whether sterile supplies near the sighting must be discarded.",
            "role": "sterilization-tech",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "sterilization-tech",
          "title": "Assess whether sterile supplies near the sighting must be discarded",
          "why": "A licensed clinical judgment call on whether compromised supply integrity is safe to use — never assumed safe by default."
        },
        {
          "detail": "Remove food sources, clean visible droppings or nesting material with appropriate disinfectant, and seal any obvious entry points temporarily (gaps, holes).",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Clean and disinfect the affected area"
        },
        {
          "detail": "Report the pest type, location, and extent; request an inspection and treatment appointment, prioritizing methods safe for a healthcare setting.\n\nRecord: vendor name, appointment date, treatment plan",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Call a licensed pest control vendor"
        },
        {
          "detail": "Weigh whether the room has been adequately cleaned and sealed against the risk of continued activity.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "close-room",
              "label": "Keep the room closed until pest control treats and clears it"
            },
            {
              "goto": "s6",
              "id": "use-with-caution",
              "label": "Use the room with increased monitoring pending treatment"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide whether the affected room can be used before pest control treatment"
        },
        {
          "detail": "Record sighting details, area closed, supplies discarded, vendor treatment date, and clearance confirmation in the facility incident log.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident and clearance"
        },
        {
          "detail": "Pest incident closed out",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Pest incident closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Pest, rodent or insect infestation discovered — Staff sees rodents, cockroaches, ants or bedbugs in the office or sterilization area.",
      "title": "Pest, rodent or insect infestation discovered",
      "trigger": "Staff sees rodents, cockroaches, ants or bedbugs in the office or sterilization area",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Generic biomedical-equipment downtime practice — isolate, tag, reroute, service, log (no named-vendor procedure) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic biomedical-equipment downtime practice — isolate, tag, reroute, service, log (no named-vendor procedure)"
          },
          "source": "Generic biomedical-equipment downtime practice — isolate, tag, reroute, service, log (no named-vendor procedure) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "fuf-009",
      "kind": "operational",
      "materials": [
        "backup handpiece or loaner cart",
        "operatory-down sign",
        "vendor service contract / support number",
        "day sheet or schedule view"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "scheduler",
        "office-manager",
        "dentist",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Power down or disconnect the failed chair, light, x-ray head or handpiece; do not attempt further use once a fault is confirmed.\n\nWhy: Continuing to use faulty electrical or pneumatic equipment risks patient or staff injury and can turn a repairable fault into a total loss.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the failure and stop use of the unit",
          "why": "Continuing to use faulty electrical or pneumatic equipment risks patient or staff injury and can turn a repairable fault into a total loss."
        },
        {
          "detail": "Place an operatory-down sign at the door and note the fault (equipment, symptom, time) on the day sheet or huddle board.\n\nWhy: A visible tag stops another team member from seating a patient in a room that cannot be used.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Tag the operatory as out of service",
          "why": "A visible tag stops another team member from seating a patient in a room that cannot be used."
        },
        {
          "detail": "Tell the office manager which operatory is down, what failed, and how many patients remain scheduled there today.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Notify the office manager"
        },
        {
          "detail": "Check the equipment closet or a nearby operatory for a functioning loaner handpiece, cart or backup unit before assuming none exists.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "o1",
              "label": "Yes — swap in the loaner or backup handpiece/cart"
            },
            {
              "goto": "s10",
              "id": "o2",
              "label": "No — the operatory is unusable today"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a working loaner or backup unit available on site?"
        },
        {
          "detail": "Bring the loaner or backup handpiece/cart into the operatory, confirm it functions, and resume the day's schedule in that room.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Swap in the backup equipment and resume"
        },
        {
          "detail": "Log room, equipment, symptom, time down/up, and that a loaner is in temporary use pending permanent repair.\n\nRecord: room, equipment, symptom, time down/up, loaner-in-use flag",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the interim fix and remaining schedule"
        },
        {
          "detail": "Call the equipment's service provider from the vendor directory, describe the fault, and get a repair ETA and reference number.\n\nWhy: A documented service ticket protects warranty coverage and gives a concrete date to communicate to staff and, if needed, patients.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Place the vendor service call",
          "why": "A documented service ticket protects warranty coverage and gives a concrete date to communicate to staff and, if needed, patients."
        },
        {
          "detail": "Log the service ticket number, technician ETA, and any quoted repair cost in the facility maintenance log.\n\nRecord: service ticket number, technician ETA, quoted repair cost",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Record repair ETA and cost estimate"
        },
        {
          "detail": "Operatory restored to service or repair scheduled",
          "id": "s9",
          "kind": "step",
          "title": "Operatory restored to service or repair scheduled"
        },
        {
          "detail": "Pull the list of appointments booked into the down operatory for the remainder of the day.",
          "id": "s10",
          "kind": "step",
          "role": "scheduler",
          "title": "Identify affected patients on today's schedule"
        },
        {
          "detail": "Check the day sheet for any open operatory or provider column that can absorb the affected appointments before calling patients to reschedule.",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "o1",
              "label": "Yes — reassign patients to an open operatory/provider"
            },
            {
              "goto": "s13",
              "id": "o2",
              "label": "No open chair — contact patients to reschedule"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "scheduler",
          "title": "Can affected patients be moved to another open operatory instead of rescheduled?"
        },
        {
          "detail": "Move each affected appointment to an available room or provider column and confirm with the front desk and clinician.",
          "id": "s12",
          "kind": "step",
          "role": "scheduler",
          "title": "Reassign patients to an open operatory"
        },
        {
          "detail": "Call each patient whose appointment cannot be moved, apologize for the inconvenience, and offer the next available slot.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Call affected patients to reschedule"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Chair, light, x-ray unit, handpiece or delivery system breaks down with patients scheduled — A single operatory's critical equipment fails and the day's schedule depends on it — loaner, reschedule, service call.",
      "title": "Chair, light, x-ray unit, handpiece or delivery system breaks down with patients scheduled",
      "trigger": "A single operatory's critical equipment fails and the day's schedule depends on it — loaner, reschedule, service call",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — PPE and disinfection principles applied generically to a contaminated-water spill",
          "source": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — PPE and disinfection principles applied generically to a contaminated-water spill",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol6/xml/CFR-2024-title29-vol6-sec1910-1030.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fuf-010",
      "kind": "operational",
      "materials": [
        "wet-floor/caution signs",
        "gloves and disposable gown",
        "disinfectant rated for bodily-fluid spills",
        "plumber/restoration contact list",
        "shop vacuum or absorbent barrier"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Anyone who sees standing wastewater or smells sewage stops using the restroom or room immediately and moves people away from it.\n\nWhy: Wastewater is a biohazard; walking through it spreads contamination into clinical areas.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Stop use of the area and clear people out",
          "why": "Wastewater is a biohazard; walking through it spreads contamination into clinical areas."
        },
        {
          "detail": "Turn off the shutoff valve at the toilet or sink, or the building main if the source is unclear.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Shut off the water supply to the affected fixture"
        },
        {
          "detail": "Place wet-floor/caution signs at every entrance to the affected area; block the doorway with a barrier if wastewater is actively flowing.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Barrier and sign the area"
        },
        {
          "detail": "Walk the extent of the wastewater spread and compare it against the floor plan for adjacent operatories, sterilization areas or record storage.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "o1",
              "label": "Yes — treat the adjacent clinical area as compromised"
            },
            {
              "goto": "s12",
              "id": "o2",
              "label": "No — contained to a restroom/non-clinical area"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is any operatory, sterilization area or record storage within the affected footprint?"
        },
        {
          "detail": "Close the affected operatory or sterilization area, reassign scheduled patients, and hold sterilization until the area is cleared.\n\nWhy: Sewage contact voids the clean/dirty separation sterilization protocols depend on.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Pause clinical use of the adjacent area and reroute patients",
          "why": "Sewage contact voids the clean/dirty separation sterilization protocols depend on."
        },
        {
          "detail": "Call the plumbing/restoration vendor from the facility contact list, describe the backup source and extent, and get an arrival time.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Call a licensed plumber or water-damage restoration contractor"
        },
        {
          "detail": "Do not mop, vacuum, or touch the affected surfaces without gloves, a disposable gown, and rated disinfectant; wait for trained cleanup if the spill is extensive.\n\nWhy: Untrained contact with raw sewage is a real exposure risk, not just an unpleasant task.",
          "id": "s7",
          "kind": "step",
          "role": "all-staff",
          "title": "Do not attempt cleanup without PPE",
          "why": "Untrained contact with raw sewage is a real exposure risk, not just an unpleasant task."
        },
        {
          "detail": "Once the source is stopped and standing water removed, disinfect all contacted surfaces with a bodily-fluid-rated product per label contact time, then air-dry or fan-dry.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Disinfect and dry the area once cleared"
        },
        {
          "detail": "Log discovery time, source, area affected, vendor called, ETA, cost, and date the area was cleared to reopen.\n\nRecord: discovery time, source, area affected, vendor called, ETA, cost, reopen-clearance date",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident and repair"
        },
        {
          "detail": "Office manager hands the incident log and vendor invoice to the owner for insurance-claim and cost decisions.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Owner reviews cost and any insurance claim"
        },
        {
          "detail": "Area disinfected, repaired, and cleared for use",
          "id": "s11",
          "kind": "step",
          "title": "Area disinfected, repaired, and cleared for use"
        },
        {
          "detail": "Keep the rest of the schedule running; only the barricaded area is out of use.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Continue clinical operations in unaffected rooms"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Sewage backup or restroom plumbing failure — A toilet or drain backs up and wastewater enters the office.",
      "title": "Sewage backup or restroom plumbing failure",
      "trigger": "A toilet or drain backs up and wastewater enters the office",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1000 (air contaminants) and NIOSH criteria for waste anesthetic gas exposure — general basis for scavenging and ventilation practice",
          "source": "OSHA 29 CFR 1910.1000 (air contaminants) and NIOSH criteria for waste anesthetic gas exposure — general basis for scavenging and ventilation practice",
          "url": "https://www.cdc.gov/niosh/"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §5142 ventilation standard",
          "source": "Cal/OSHA Title 8 §5142 ventilation standard"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "fuf-011",
      "kind": "operational",
      "materials": [
        "backup oxygen cylinder",
        "pulse oximeter",
        "scavenging system alarm/gauge",
        "gas-line shutoff valve location card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Immediately close the nitrous flowmeter. Confirm oxygen is actually flowing to the patient -- if the oxygen supply itself has failed (e.g. the oxygen cylinder is the one that ran dry), immediately swap in the backup oxygen cylinder before anything else. Once oxygen delivery is confirmed, run 100% oxygen for at least 5 minutes regardless of what triggered the alarm.\n\nWhy: Removing the patient from nitrous and running oxygen reduces the risk of diffusion hypoxia after nitrous sedation; the 5-minute figure is standard clinical practice, not a duration fixed by the public OSHA/NIOSH sources cited above, so the treating dentist's own written sedation protocol governs the exact duration pending licensed review.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Stop nitrous flow and switch the patient to 100% oxygen",
          "why": "Removing the patient from nitrous and running oxygen reduces the risk of diffusion hypoxia after nitrous sedation; the 5-minute figure is standard clinical practice, not a duration fixed by the public OSHA/NIOSH sources cited above, so the treating dentist's own written sedation protocol governs the exact duration pending licensed review."
        },
        {
          "detail": "Watch skin color, respiratory rate, and verbal responsiveness; place a pulse oximeter if one is not already on.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Check the patient's color, breathing and responsiveness"
        },
        {
          "detail": "Confirm normal skin color, steady breathing, and clear responsiveness against the pulse oximeter reading before deciding whether to keep troubleshooting or escalate to EMS.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "o1",
              "label": "Yes — patient is stable on room air/oxygen"
            },
            {
              "goto": "s11",
              "id": "o2",
              "label": "No — patient shows distress, drowsiness beyond expected, or abnormal vitals"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient stable and comfortable?"
        },
        {
          "detail": "Open windows/doors if available and confirm room ventilation/scavenging exhaust is running.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Ventilate the room"
        },
        {
          "detail": "Check the cylinder gauge for empty, listen/smell for a hose or connector leak, and check the scavenging system alarm readout.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the fault source"
        },
        {
          "detail": "Check the cylinder pressure gauge, listen and smell for a hose or connector leak, and check the scavenging alarm readout to determine the fault type.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "o1",
              "label": "Empty cylinder — swap to a full backup cylinder"
            },
            {
              "goto": "s12",
              "id": "o2",
              "label": "Suspected leak, faulty hose or connector — do not restart gas"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the cause an empty cylinder, or a leak/alarm fault?"
        },
        {
          "detail": "Replace the empty cylinder with the backup, check connections are secure, and confirm no odor or gauge drop before resuming.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Swap in the backup cylinder and pressure-test"
        },
        {
          "detail": "The treating dentist confirms the patient is stable and the supply is verified sound before nitrous is reintroduced, or elects to complete the case on local anesthesia alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off before resuming the case with nitrous.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off before resuming the case with nitrous"
        },
        {
          "detail": "Log time of alarm, cause found, action taken (cylinder swap or line shutoff), whether the case was completed or deferred, and any vendor ticket number.\n\nRecord: alarm time, cause found, action taken (cylinder swap or line shutoff), case outcome, vendor ticket number",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the fault and resolution"
        },
        {
          "detail": "Supply fault resolved and case completed, deferred, or escalated to EMS",
          "id": "s10",
          "kind": "step",
          "title": "Supply fault resolved and case completed, deferred, or escalated to EMS"
        },
        {
          "detail": "If the patient does not recover promptly on 100% oxygen or shows signs of hypoxia, call 911/EMS immediately and continue oxygen and monitoring until they arrive.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Emergency escalation if patient is not stable.",
            "type": "safety"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Emergency escalation if patient is not stable"
        },
        {
          "detail": "Close the shutoff valve for the affected line and tag the operatory out of use for nitrous until a service technician inspects it.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Shut off the gas line at the main valve"
        },
        {
          "detail": "Call the gas-delivery equipment service vendor to inspect lines, connectors and the scavenging system before nitrous is used again in that operatory.",
          "id": "s13",
          "kind": "step",
          "role": "it-vendor",
          "title": "Schedule a service technician to inspect the gas system"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Nitrous oxide or oxygen line leak, alarm or empty cylinder mid-case — The scavenging alarm sounds, a cylinder runs dry during sedation, or a gas odor is noticed.",
      "title": "Nitrous oxide or oxygen line leak, alarm or empty cylinder mid-case",
      "trigger": "The scavenging alarm sounds, a cylinder runs dry during sedation, or a gas odor is noticed",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.74–1301.76 — theft/loss of controlled substances reportable within one business day",
          "source": "DEA 21 CFR 1301.74–1301.76 — theft/loss of controlled substances reportable within one business day",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title21-vol9/xml/CFR-2024-title21-vol9-sec1301-74.xml"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Breach Notification Rule, 45 CFR §164.400-414 -- four-factor risk assessment and 60-day notification deadline",
          "source": "HIPAA Breach Notification Rule, 45 CFR §164.400-414 -- four-factor risk assessment and 60-day notification deadline",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/xml/CFR-2024-title45-vol2-sec164-404.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "fuf-012",
      "kind": "operational",
      "materials": [
        "alarm company contact and account/code",
        "practice owner and office manager phone numbers",
        "security camera/DVR access",
        "controlled-substance inventory log",
        "insurance policy contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "practice-owner",
        "compliance-officer",
        "it-vendor",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If you find a forced door, broken window, or a tripped alarm at opening, do not go inside. Back away, go somewhere safe, and call 911 to report a possible break-in before doing anything else.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Do not enter — call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Do not enter — call 911 first"
        },
        {
          "detail": "Once 911 is called, call the office manager and practice owner to report the situation and your location.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Call the office manager or owner"
        },
        {
          "detail": "Stay outside at a safe distance until police arrive and confirm the building is clear and safe to enter.\n\nWhy: An intruder may still be inside; entering before the building is cleared risks a direct confrontation.",
          "id": "s3",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1200,
          "title": "Wait for police to clear the building",
          "why": "An intruder may still be inside; entering before the building is cleared risks a direct confrontation."
        },
        {
          "detail": "Accompany police through the office to identify what is missing, damaged, or disturbed; do not touch anything until police say it is fine.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Walk the building with police once cleared"
        },
        {
          "detail": "Check the controlled-substance cabinet/log, equipment, cash drawer, records room, and computers/servers for anything missing, opened, or damaged.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Inventory what is missing or disturbed"
        },
        {
          "detail": "Check the controlled-substance log against the physical inventory, and check whether the records room or prescription pad storage was disturbed or opened.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "o1",
              "label": "Yes — a DEA/records compliance report is needed"
            },
            {
              "goto": "s9",
              "id": "o2",
              "label": "No controlled items or records involved"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are controlled substances, prescription pads, or patient records missing or accessed?"
        },
        {
          "detail": "Compliance officer reviews what was taken and files the DEA theft-or-loss report within one business day of discovery, and evaluates whether a HIPAA breach notification is triggered using the Breach Notification Rule's four-factor risk assessment (45 CFR §164.402), with any required notification made within 60 days of discovery per 45 CFR §164.404.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review before filing DEA theft-or-loss and any breach notification.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review before filing DEA theft-or-loss and any breach notification"
        },
        {
          "detail": "Record the DEA theft-or-loss report confirmation number and any breach-notification determination and filing date.\n\nRecord: DEA report confirmation number, breach-notification determination, filing date",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the required reports"
        },
        {
          "detail": "Office manager hands the police report number, photos, and inventory list to the owner to open an insurance claim.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Owner files the insurance claim"
        },
        {
          "detail": "Rekey affected locks, change the alarm code, and confirm cameras and the alarm panel are functioning before reopening.",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Change locks, codes and reset the alarm system"
        },
        {
          "detail": "If the building is secure and cleared, notify staff and proceed with the day; otherwise close for the day and have front desk call scheduled patients.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Decide whether to open for scheduled patients today"
        },
        {
          "detail": "Log discovery time, police report number, items affected, reports filed, and reopening time.\n\nRecord: discovery time, police report number, items affected, reports filed, reopening time",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the full incident timeline"
        },
        {
          "detail": "Building secured, reports filed, practice reopened or safely closed for the day",
          "id": "s13",
          "kind": "step",
          "title": "Building secured, reports filed, practice reopened or safely closed for the day"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Break-in, burglary or tripped alarm discovered at opening — The opener finds a forced door, broken window, alarm event, or missing equipment, drugs or records — do not enter; call 911, then the owner.",
      "title": "Break-in, burglary or tripped alarm discovered at opening",
      "trigger": "The opener finds a forced door, broken window, alarm event, or missing equipment, drugs or records — do not enter; call 911, then the owner",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.74–1301.76 — theft/loss of controlled substances reportable within one business day, applies once safe",
          "source": "DEA 21 CFR 1301.74–1301.76 — theft/loss of controlled substances reportable within one business day, applies once safe",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title21-vol9/xml/CFR-2024-title21-vol9-sec1301-74.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "fuf-013",
      "kind": "operational",
      "materials": [
        "silent panic alarm button",
        "internal security reference materials",
        "post-incident support/EAP contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "front-desk",
        "office-manager",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Stay calm, do not resist or argue, and comply with the demand. As soon as it is safe, call or have someone call 911; use a silent panic alarm if one is available and it does not put anyone at more risk to activate it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Comply, do not resist — get 911 called as soon as it is safe.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Comply, do not resist — get 911 called as soon as it is safe"
        },
        {
          "detail": "If it is safe to do so, quietly direct patients and staff away from the immediate area toward an exit or a room away from the incident.\n\nWhy: Reducing the number of people near the situation lowers the chance anyone else is drawn into a confrontation.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Move patients and staff away from the area",
          "why": "Reducing the number of people near the situation lowers the chance anyone else is drawn into a confrontation."
        },
        {
          "detail": "After the person leaves, do not chase or follow them. Note direction of travel, description, and any vehicle if it can be seen safely from inside.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Observe safely, do not pursue"
        },
        {
          "detail": "Check that every staff member and patient is accounted for and uninjured; provide first aid or call EMS again for any injury.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Account for everyone's safety"
        },
        {
          "detail": "Is anyone injured or in medical distress?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "o1",
              "label": "No injuries reported"
            },
            {
              "goto": "s13",
              "id": "o2",
              "label": "Yes — someone needs medical attention"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is anyone injured or in medical distress?"
        },
        {
          "detail": "Do not clean up, move items, or let staff touch surfaces the person may have touched until police say it is fine.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Preserve the scene for police"
        },
        {
          "detail": "Cooperate with responding police, provide descriptions, and once cleared, inventory any cash, controlled substances, or property taken.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Give a statement to police and inventory what was taken"
        },
        {
          "detail": "Office manager or owner decides whether to close the practice for the rest of the day to support staff and complete the police report, and authorizes patient rescheduling calls.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor authorizes closing for the remainder of the day if needed.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor authorizes closing for the remainder of the day if needed"
        },
        {
          "detail": "Call remaining scheduled patients to reschedule, without describing the incident in detail.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Reschedule remaining patients if the office closes"
        },
        {
          "detail": "Offer staff time to decompress, and share the practice's employee assistance or counseling resource contact for anyone who wants support after the incident.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Offer staff support"
        },
        {
          "detail": "Log the police report number, time, items taken, injuries, and — if controlled substances were taken — the DEA theft-or-loss report confirmation number filed within one business day.\n\nRecord: police report number, time, items taken, injuries, DEA report confirmation number if applicable",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident and file the DEA report if controlled substances were taken"
        },
        {
          "detail": "Scene secured, everyone accounted for, reports filed",
          "id": "s12",
          "kind": "step",
          "title": "Scene secured, everyone accounted for, reports filed"
        },
        {
          "detail": "Provide first aid within your training and keep the person calm and comfortable until EMS takes over.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Stay with the injured person until EMS arrives"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Robbery or demand for drugs or cash during hours — A person demands cash, controlled substances or valuables, with or without a visible weapon.",
      "title": "Robbery or demand for drugs or cash during hours",
      "trigger": "A person demands cash, controlled substances or valuables, with or without a visible weapon",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.74–1301.76 — theft or significant loss of controlled-substance prescription forms/authority reportable within one business day",
          "source": "DEA 21 CFR 1301.74–1301.76 — theft or significant loss of controlled-substance prescription forms/authority reportable within one business day",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title21-vol9/xml/CFR-2024-title21-vol9-sec1301-74.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fuf-014",
      "kind": "operational",
      "materials": [
        "DEA registration number",
        "e-prescribing account access",
        "state prescription drug monitoring program (PDMP) login",
        "pharmacy contact who called"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Check the storage location for the tamper-resistant pad, or call the reporting pharmacy back at their listed number to confirm details of the suspicious prescription.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the pad is missing or the report is genuine"
        },
        {
          "detail": "Confirm which type of security event occurred based on what the dentist found missing in the pad's storage location or what the reporting pharmacy described about the suspicious prescription.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "Paper pad missing or stolen"
            },
            {
              "goto": "s10",
              "id": "o2",
              "label": "E-prescribing account/credential compromised"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this a stolen/missing paper pad, or a compromised e-prescribing credential?"
        },
        {
          "detail": "Record the pad's serial number range as voided in the prescribing log so any prescription from that range is flagged as invalid.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Void the missing pad's serial range"
        },
        {
          "detail": "Call frequently used local pharmacies to alert them that pads from the voided serial range should not be filled and should be reported if presented.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Alert nearby pharmacies"
        },
        {
          "detail": "Compliance officer confirms the facts with the dentist and files the DEA theft-or-loss report promptly upon discovery, per DEA reporting requirements (21 CFR §1301.74(c)).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews before filing the DEA report.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews before filing the DEA report"
        },
        {
          "detail": "Log the DEA report confirmation number, pharmacies notified, voided serial range or locked credential, and date.\n\nRecord: DEA report confirmation number, pharmacies notified, voided serial range or locked credential, date",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the DEA report and pharmacy notifications"
        },
        {
          "detail": "Order a new tamper-resistant pad from a secured source, or work with the e-prescribing vendor to reissue the dentist's credential, and store it in the locked location once received.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Reissue a new pad or credential"
        },
        {
          "detail": "The dentist confirms the account or pad is secured and prescribing may resume before writing any further prescriptions.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off that prescribing is safe to resume.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off that prescribing is safe to resume"
        },
        {
          "detail": "Credential secured, reports filed, prescribing resumed safely",
          "id": "s9",
          "kind": "step",
          "title": "Credential secured, reports filed, prescribing resumed safely"
        },
        {
          "detail": "IT vendor or office manager disables or resets the compromised e-prescribing credential immediately so no further prescriptions can be sent on it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Lock the e-prescribing account immediately.",
            "role": "it-vendor",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "it-vendor",
          "title": "Lock the e-prescribing account immediately"
        },
        {
          "detail": "Review the e-prescribing account's recent sent history and the state PDMP for any prescription the dentist did not authorize.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Review recent prescription history for fraud"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Prescription pad stolen or e-prescribing credential compromised — Tamper-resistant pads are missing, or a pharmacy calls about a prescription the dentist did not write.",
      "title": "Prescription pad stolen or e-prescribing credential compromised",
      "trigger": "Tamper-resistant pads are missing, or a pharmacy calls about a prescription the dentist did not write",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Generic physical-access-control best practice — reissue credentials and change codes on loss (no named-vendor procedure) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic physical-access-control best practice — reissue credentials and change codes on loss (no named-vendor procedure)"
          },
          "source": "Generic physical-access-control best practice — reissue credentials and change codes on loss (no named-vendor procedure) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "fuf-015",
      "kind": "operational",
      "materials": [
        "key/badge issuance log",
        "alarm company contact and account number",
        "locksmith/access-control vendor contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the key/badge issuance log to identify exactly which key, badge or code is unaccounted for and when it was last confirmed present.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm what is missing and since when"
        },
        {
          "detail": "Check the issuance log against current staff records to determine whether the item is simply misplaced by a current employee or was never returned by someone no longer employed.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "Lost/misplaced by a current employee"
            },
            {
              "goto": "s3",
              "id": "o2",
              "label": "Held by a departed employee who did not return it"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a lost item, or held by an employee who has left?"
        },
        {
          "detail": "Office manager brings the situation and estimated cost to the practice owner to authorize rekeying locks, reissuing a badge, or changing the alarm code.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor authorizes rekeying/reissuing cost.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor authorizes rekeying/reissuing cost"
        },
        {
          "detail": "Change the building alarm code with the alarm company and update the list of staff who know the new code.\n\nWhy: A code is the fastest thing to change and closes the biggest exposure while physical rekeying is arranged.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Change the alarm code immediately",
          "why": "A code is the fastest thing to change and closes the biggest exposure while physical rekeying is arranged."
        },
        {
          "detail": "Check the issuance log entry for whether the missing item recorded is a physical key, an electronic badge, or an alarm code only.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "o1",
              "label": "Yes — a physical key is unaccounted for"
            },
            {
              "goto": "s7",
              "id": "o2",
              "label": "No — only a badge or code, no physical key involved"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was a physical key (not just a badge) lost or unreturned?"
        },
        {
          "detail": "Call a locksmith to rekey every lock the missing key opens, and issue new keys only to current staff who need them.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Rekey the affected locks"
        },
        {
          "detail": "If the site uses electronic badges, deactivate the missing badge's credential in the access-control system so it no longer opens any door.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Deactivate the badge in the access-control system"
        },
        {
          "detail": "Log the item lost or unreturned, action taken (rekey, code change, badge deactivation), date, and cost.\n\nRecord: item lost or unreturned, action taken (rekey/code change/badge deactivation), date, cost",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the key/badge issuance log"
        },
        {
          "detail": "If a departed employee caused the loss, confirm the practice's offboarding checklist requires key/badge return and alarm code awareness at exit going forward.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Add the fix to the offboarding checklist if this was a departed employee"
        },
        {
          "detail": "Access secured and issuance log updated",
          "id": "s10",
          "kind": "step",
          "title": "Access secured and issuance log updated"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Keys, access badge or alarm code lost or held by a departed employee — A key or badge cannot be found, or an employee leaves without returning it.",
      "title": "Keys, access badge or alarm code lost or held by a departed employee",
      "trigger": "A key or badge cannot be found, or an employee leaves without returning it",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; CDC dental infection-control guidance does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CDC Guidelines for Infection Control in Dental Health-Care Settings addresses waterline/biofilm management, sterilization and disinfection procedures, hand hygiene and PPE, and environmental infection control — not equipment breakdowns, security breaches, theft, or plumbing failures as operational-emergency events. None of the eight cited protocols (fuf-009 through fuf-016) concerns infection-control practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — waterlines, boil-water advisories, sterilization monitoring",
              "url": "https://www.cdc.gov/dental-infection-control/"
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); CDC dental infection-control guidance does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; DEA controlled-substance security regulations do not govern most of this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR 1301.74-1301.76 addresses controlled-substance physical security requirements, theft-prevention controls, employee vetting for access to controlled substances, and safe storage — and separately requires a theft-or-loss report within one business day for missing controlled substances. It does not address equipment breakdown (fuf-009), sewage backup (fuf-010), a nitrous/O2 line leak (fuf-011), a general break-in (fuf-012), lost keys/badge (fuf-015), or an unauthorized person in a clinical area generally (fuf-016). Even fuf-013 (robbery demanding drugs) and fuf-014 (stolen prescription pad) only partially engage DEA's controlled-substance-security scope rather than being fully governed by it.",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 — controlled-substance/pad security and theft-or-loss report within one business day",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); DEA controlled-substance security regulations do not govern most of this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — generic functional equivalent for the remaining facility/security incident-response steps"
          },
          "repaired": {
            "action": "generic",
            "evidence": "45 CFR 164.310 text (via ecfr.gov, part 164) scopes the four safeguards to 'Facility Access Controls', 'Workstation Use', 'Workstation Security', and 'Device and Media Controls', each defined in terms of access to electronic information systems and the ePHI they hold. None of the eight cited titles — chair/light/x-ray/handpiece breakdown, sewage/plumbing failure, nitrous/oxygen line leak, break-in, robbery, prescription-pad theft, lost keys/badge/alarm code, unauthorized person in a clinical/records area — is framed as an ePHI-system access event; searching for a facilities/OSHA-general-duty or generic emergency-procedures authority that covers all eight as a set turned up none.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule physical safeguards, 45 CFR §164.310",
              "url": null
            }
          },
          "source": "No single regulation governs this set. 45 CFR §164.310 (HIPAA Security Rule) reaches only physical safeguards for electronic PHI systems (facility access controls, workstation use/security, device and media controls) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; state elevator-safety and building/fire code does not govern this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The current source text names only a generic, jurisdiction-unspecified 'elevator safety code and local building/fire code.' None of the eight cited protocols (fuf-009 equipment breakdown, fuf-010 sewage backup, fuf-011 nitrous/O2 leak, fuf-012 break-in, fuf-013 robbery, fuf-014 stolen prescription pad, fuf-015 lost keys/badge, fuf-016 unauthorized person in a clinical area) is an elevator, building-code, or fire-code subject — the list does not even include an elevator-adjacent item that would justify the citation's own stated scope.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic — jurisdiction-specific)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); state elevator-safety and building/fire code does not govern this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule physical safeguards — facility access controls, 45 CFR §164.310(a)",
          "source": "HIPAA Security Rule physical safeguards — facility access controls, 45 CFR §164.310(a)",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/xml/CFR-2024-title45-vol2-sec164-310.xml"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Breach Notification Rule, 45 CFR §164.400-414",
          "source": "HIPAA Breach Notification Rule, 45 CFR §164.400-414",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/xml/CFR-2024-title45-vol2-sec164-404.xml"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "fuf-016",
      "kind": "operational",
      "materials": [
        "visitor sign-in log",
        "staff photo roster for identification",
        "PHI/HIPAA incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Any staff member who finds an unescorted, unidentified person past the reception line approaches calmly and asks their name and purpose.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Approach calmly and ask who they are and who they are there to see"
        },
        {
          "detail": "Ask for identification and the name of the staff member or department they are there to see, and check the visitor log or expected-delivery list for a match.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "Yes — legitimate visitor, just unescorted"
            },
            {
              "goto": "s9",
              "id": "o2",
              "label": "No clear reason, or they refuse to identify themselves"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "all-staff",
          "title": "Does the person have a legitimate reason and identification (vendor, delivery, escorted family member)?"
        },
        {
          "detail": "Walk the visitor to their intended destination or back to the reception area, and have them sign the visitor log if they have not already.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Escort them to where they need to be or back to the lobby"
        },
        {
          "detail": "Identify which room, screens, charts, or drug storage the person was near or could have seen or touched.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Determine what area and materials they had access to"
        },
        {
          "detail": "If the person had visibility into patient charts, open screens, or the records room, treat it as a potential PHI exposure and escalate to the compliance officer for a breach assessment rather than deciding informally.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Assess whether this is a PHI exposure requiring compliance review.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "Assess whether this is a PHI exposure requiring compliance review"
        },
        {
          "detail": "Log time, description of the person, area accessed, materials potentially exposed, and the compliance officer's assessment outcome.\n\nRecord: Log time, description of the person, area accessed, materials potentially exposed, and the compliance officer's assessment outcome.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Check whether a door was propped, a badge reader failed, or front-desk coverage had a gap, and correct the physical cause.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Review whether the access point needs a fix"
        },
        {
          "detail": "Person escorted out, exposure assessed, access point reviewed",
          "id": "s8",
          "kind": "step",
          "title": "Person escorted out, exposure assessed, access point reviewed"
        },
        {
          "detail": "Firmly and calmly walk the person back to the exit; do not leave them alone in the area and do not physically confront them if they resist.\n\nWhy: De-escalating and escorting avoids confrontation while still ending unsupervised access to clinical or records areas.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Escort the person out and do not leave them alone",
          "why": "De-escalating and escorting avoids confrontation while still ending unsupervised access to clinical or records areas."
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Unauthorized person found in a clinical, records or drug area — A visitor, vendor or unknown person is found past the reception line without an escort.",
      "title": "Unauthorized person found in a clinical, records or drug area",
      "trigger": "A visitor, vendor or unknown person is found past the reception line without an escort",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR §1301.76(b) (practitioners) / §1301.74(c) (non-practitioners) — controlled-substance theft/loss notification only",
          "repaired": {
            "action": "reduce",
            "evidence": "'21 CFR 1301.76(b) requires registrants to notify the Field Division Office of the DEA in their area, in writing, of the theft or significant loss of any controlled substances within one business day of discovery of such loss or theft.' Similarly, '21 CFR 1301.74(c) requires non-practitioners to preliminarily notify their local DEA Field Division Office, in writing, of the theft or significant loss of any controlled substances within one business day of discovering such theft or loss.' (eCFR / DEA Diversion Control, via search.)",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 (security, theft/loss report within one business day)",
              "url": null
            }
          },
          "source": "21 CFR §1301.76(b) and §1301.74(c) (theft/significant-loss notification to the DEA Field Division Office within one business day of discovery). Scope: applies only when the underlying incident IS a theft or significant loss of controlled substances — does NOT reach a generic after-hours alarm call (fuf-017), generic vandalism/property damage (fuf-018), a generic camera-footage request (fuf-019), or generic after-hours cleaning-crew access (fuf-022) unless controlled substances were actually stolen or lost as part of that event.",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.76"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plans"
        },
        {
          "kind": "generic",
          "label": "State elevator safety code and local building/fire code — trapped-elevator response only",
          "repaired": {
            "action": "reduce",
            "evidence": "Elevator entrapment response (notify building management/elevator maintenance contractor, keep occupants calm, do not attempt self-extraction) is the subject matter state elevator safety codes and local building/fire codes actually regulate; alarm-monitoring calls, exterior vandalism, a restraining-order subject's appearance, and parking-lot personnel safety are security/HR incident types with no code provision cited or found to govern them.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic)",
              "url": null
            }
          },
          "source": "State elevator safety code and local building/fire code. Scope: fuf-007 (patient or staff trapped in the building elevator) only — does NOT reach fuf-017 (after-hours alarm/monitoring call), fuf-018 (vandalism/graffiti/property damage), fuf-023 (banned individual/restraining-order subject appears), or fuf-024 (staff parking-lot safety after dark), which are security/personnel-safety matters with no elevator, building, or fire-code content."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "fuf-017",
      "kind": "operational",
      "materials": [
        "monitoring-company account number and verbal password",
        "keyholder call list with current phone numbers",
        "police non-emergency line for the office's jurisdiction",
        "building or suite key",
        "alarm system codes and zone map"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask for the account number and the zone that triggered. If in doubt, hang up and call the monitoring company back at the number on file, not a number the caller provides.\n\nWhy: A fake alarm call is a known pretext for pulling a keyholder to the building or extracting information over the phone.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Verify the call is genuinely from the monitoring company",
          "why": "A fake alarm call is a known pretext for pulling a keyholder to the building or extracting information over the phone."
        },
        {
          "detail": "Weigh which zone triggered (perimeter door vs. an internal motion sensor vs. a glass-break sensor) and whether the monitoring company has already dispatched police.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "wait-police",
              "label": "Ask the monitoring company to dispatch police and wait for their confirmation before anyone approaches the building"
            },
            {
              "goto": "s3",
              "id": "respond-direct",
              "label": "A keyholder drives to the building without police confirmation"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to respond in person or wait for police confirmation"
        },
        {
          "detail": "If any door, window or lock shows damage, or the monitoring company reports a suspicious circumstance, do not enter — stay outside and wait for police, exactly as in the break-in-at-opening protocol.\n\nWhy: Entering a building where an intruder may still be present is a safety risk no operational goal justifies.",
          "gate": {
            "ack": "I confirm I have completed this step as written: No one enters the building alone if forced entry is suspected.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "No one enters the building alone if forced entry is suspected",
          "why": "Entering a building where an intruder may still be present is a safety risk no operational goal justifies."
        },
        {
          "detail": "Walk the perimeter with police or after they clear the scene: check doors, windows, the drug storage area and any obvious missing equipment.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Once cleared by police or confirmed safe, check for signs of entry or damage"
        },
        {
          "detail": "Common false-alarm causes: a door not fully latched, an HVAC-triggered motion sensor, a low battery, or staff forgetting to disarm on entry.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "false-alarm",
              "label": "False alarm — identify and fix the cause (weatherstripping, sensor placement, battery)"
            },
            {
              "goto": "s6",
              "id": "genuine-event",
              "label": "Signs of entry or damage found — route to the break-in protocol and file a police report"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Determine whether this was a false alarm or a genuine event"
        },
        {
          "detail": "Call the monitoring company back to confirm the zone is clear and the system is armed before leaving the building.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Rearm the system and confirm the monitoring company shows it active"
        },
        {
          "detail": "Record call time, zone triggered, keyholder who responded, whether police were dispatched, cause found, and any follow-up repair needed, in the facility incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the alarm event"
        },
        {
          "detail": "Alarm event closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Alarm event closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "After-hours alarm or monitoring-company call — The alarm company calls a keyholder about a triggered sensor at night or on a weekend.",
      "title": "After-hours alarm or monitoring-company call",
      "trigger": "The alarm company calls a keyholder about a triggered sensor at night or on a weekend",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR §1301.76(b) (practitioners) / §1301.74(c) (non-practitioners) — controlled-substance theft/loss notification only",
          "repaired": {
            "action": "reduce",
            "evidence": "'21 CFR 1301.76(b) requires registrants to notify the Field Division Office of the DEA in their area, in writing, of the theft or significant loss of any controlled substances within one business day of discovery of such loss or theft.' Similarly, '21 CFR 1301.74(c) requires non-practitioners to preliminarily notify their local DEA Field Division Office, in writing, of the theft or significant loss of any controlled substances within one business day of discovering such theft or loss.' (eCFR / DEA Diversion Control, via search.)",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 (security, theft/loss report within one business day)",
              "url": null
            }
          },
          "source": "21 CFR §1301.76(b) and §1301.74(c) (theft/significant-loss notification to the DEA Field Division Office within one business day of discovery). Scope: applies only when the underlying incident IS a theft or significant loss of controlled substances — does NOT reach a generic after-hours alarm call (fuf-017), generic vandalism/property damage (fuf-018), a generic camera-footage request (fuf-019), or generic after-hours cleaning-crew access (fuf-022) unless controlled substances were actually stolen or lost as part of that event.",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.76"
        },
        {
          "kind": "generic",
          "label": "State elevator safety code and local building/fire code — trapped-elevator response only",
          "repaired": {
            "action": "reduce",
            "evidence": "Elevator entrapment response (notify building management/elevator maintenance contractor, keep occupants calm, do not attempt self-extraction) is the subject matter state elevator safety codes and local building/fire codes actually regulate; alarm-monitoring calls, exterior vandalism, a restraining-order subject's appearance, and parking-lot personnel safety are security/HR incident types with no code provision cited or found to govern them.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic)",
              "url": null
            }
          },
          "source": "State elevator safety code and local building/fire code. Scope: fuf-007 (patient or staff trapped in the building elevator) only — does NOT reach fuf-017 (after-hours alarm/monitoring call), fuf-018 (vandalism/graffiti/property damage), fuf-023 (banned individual/restraining-order subject appears), or fuf-024 (staff parking-lot safety after dark), which are security/personnel-safety matters with no elevator, building, or fire-code content."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "fuf-018",
      "kind": "operational",
      "materials": [
        "camera or phone for photographing damage",
        "police non-emergency line",
        "property/liability insurance policy contact",
        "building manager or landlord contact",
        "graffiti-removal or repair vendor contact"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Look for broken glass, exposed wiring, or anyone still present before walking up to the damaged area.\n\nWhy: Fresh vandalism can leave hazards (glass, sharp metal) or the person responsible may still be nearby.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm no one is on scene and the immediate area is safe to approach",
          "why": "Fresh vandalism can leave hazards (glass, sharp metal) or the person responsible may still be nearby."
        },
        {
          "detail": "Take wide shots showing location and close-ups of the damage itself, with a visible timestamp if possible.\n\nWhy: Photos taken before cleanup are the primary evidence for a police report and an insurance claim.\n\nRecord: photos of damage, date/time discovered",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Photograph the damage from multiple angles before touching or cleaning anything",
          "why": "Photos taken before cleanup are the primary evidence for a police report and an insurance claim."
        },
        {
          "detail": "Weigh the scale of damage, whether an insurance claim will need a report number, and whether the same target has recurred.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "file-report",
              "label": "File a police report using the non-emergency line and keep the report number"
            },
            {
              "goto": "s4",
              "id": "no-report",
              "label": "Minor cosmetic damage — skip the police report"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide whether to file a police report"
        },
        {
          "detail": "Share the photos, any police report number, and an initial estimate of repair scope with the practice owner and building manager as applicable.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the practice owner and, if leased, the landlord or building manager"
        },
        {
          "detail": "Weigh estimated repair cost against the policy deductible before opening a claim.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "file-claim",
              "label": "Repair cost exceeds the deductible — open a property/liability claim with photos and the police report number"
            },
            {
              "goto": "s6",
              "id": "no-claim",
              "label": "Cost is below the deductible — pay for repair directly and skip the claim"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to file an insurance claim"
        },
        {
          "detail": "Contact the appropriate vendor (glass, signage, painting) and get a repair date; put temporary signage or a barrier over the damage in the meantime if it affects safety or patient perception.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule repair or graffiti removal"
        },
        {
          "detail": "Record discovery time, description, photos on file, police report number if any, claim status, and repair completion date in the facility incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Vandalism incident closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Vandalism incident closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Vandalism, graffiti or property damage to the exterior — Staff finds broken signage, graffiti, damaged doors or a smashed vehicle in the lot.",
      "title": "Vandalism, graffiti or property damage to the exterior",
      "trigger": "Staff finds broken signage, graffiti, damaged doors or a smashed vehicle in the lot",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA physical safeguards 45 CFR 164.310",
          "source": "HIPAA physical safeguards 45 CFR 164.310"
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR §1301.76(b) (practitioners) / §1301.74(c) (non-practitioners) — controlled-substance theft/loss notification only",
          "repaired": {
            "action": "reduce",
            "evidence": "'21 CFR 1301.76(b) requires registrants to notify the Field Division Office of the DEA in their area, in writing, of the theft or significant loss of any controlled substances within one business day of discovery of such loss or theft.' Similarly, '21 CFR 1301.74(c) requires non-practitioners to preliminarily notify their local DEA Field Division Office, in writing, of the theft or significant loss of any controlled substances within one business day of discovering such theft or loss.' (eCFR / DEA Diversion Control, via search.)",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 (security, theft/loss report within one business day)",
              "url": null
            }
          },
          "source": "21 CFR §1301.76(b) and §1301.74(c) (theft/significant-loss notification to the DEA Field Division Office within one business day of discovery). Scope: applies only when the underlying incident IS a theft or significant loss of controlled substances — does NOT reach a generic after-hours alarm call (fuf-017), generic vandalism/property damage (fuf-018), a generic camera-footage request (fuf-019), or generic after-hours cleaning-crew access (fuf-022) unless controlled substances were actually stolen or lost as part of that event.",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.76"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fuf-019",
      "kind": "operational",
      "materials": [
        "security camera system login",
        "footage request log",
        "written subpoena or law-enforcement request form, if applicable",
        "release/authorization form",
        "storage device or secure transfer method for exported clips"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Determine whether the requester is the patient themselves, a police officer, an attorney, or an insurance investigator, and get the request in writing where possible.\n\nWhy: The legal basis for release differs by requester — a patient asking about their own visit is different from a third party asking about someone else.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify who is asking and in what capacity",
          "why": "The legal basis for release differs by requester — a patient asking about their own visit is different from a third party asking about someone else."
        },
        {
          "detail": "No footage is reviewed, exported or shared by front-of-house staff without compliance sign-off, because footage may show identifiable patients.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Route every footage request to the compliance officer before any footage is pulled or shared"
        },
        {
          "detail": "A patient may request footage of their own visit with a signed authorization; police or attorneys need a subpoena, court order, or the patient's written authorization unless an exception applies. When in doubt, do not release and consult legal counsel.\n\nWhy: Releasing footage that identifies patients without a valid basis is a privacy exposure, not just a courtesy.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm a valid legal basis exists before any footage is exported or shared.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm a valid legal basis exists before any footage is exported or shared",
          "why": "Releasing footage that identifies patients without a valid basis is a privacy exposure, not just a courtesy."
        },
        {
          "detail": "Weigh whether the request is properly authorized, needs a subpoena, or should be declined.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "proceed-authorized",
              "label": "Valid authorization, subpoena, or court order on file — proceed to export"
            },
            {
              "goto": "s5",
              "id": "decline-pending",
              "label": "No valid basis yet — tell the requester what documentation is needed and hold the request"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Decide how to proceed based on the legal basis found"
        },
        {
          "detail": "Pull the narrowest clip that answers the request — not a full day or full system export — and save it to a secure, access-controlled location.\n\nWhy: Minimizing what is exported limits exposure of other patients who appear in the same footage but are not part of the request.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Export only the specific time range and camera relevant to the request",
          "why": "Minimizing what is exported limits exposure of other patients who appear in the same footage but are not part of the request."
        },
        {
          "detail": "Record requester identity, legal basis documentation, time range exported, who approved it, and to whom it was delivered, in the footage-request log.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the release"
        },
        {
          "detail": "Footage request closed out",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Footage request closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Request for security-camera footage by patient, police or attorney — Someone asks for video of an incident in the reception area or parking lot.",
      "title": "Request for security-camera footage by patient, police or attorney",
      "trigger": "Someone asks for video of an incident in the reception area or parking lot",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response) — generic functional equivalent; no single federal or Cal/OSHA standard in this citation governs this bundle"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched OSHA 29 CFR 1910.38 (Emergency Action Plans — written fire/evacuation procedures, alarm systems, exit routes, employee accounting after evacuation) and Cal/OSHA Title 8 §3395 (Heat Illness Prevention, scoped to OUTDOOR places of employment) and §5142 (general ventilation). None of these three standards addresses burglary, robbery, theft of a prescription pad or e-prescribing credential, lost keys/access badges, an unauthorized person in a clinical area, equipment breakdown, or sewage backup — the fuf-009 through fuf-016 protocol family this citation is stapled across. Only a nitrous/O2 line leak (fuf-011) has any plausible tie to a ventilation standard, and even that is a stretch for an emergency-response protocol rather than a facility-ventilation design standard.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans; Cal/OSHA Title 8 §3395 (heat), §5142 (ventilation)",
              "url": null
            }
          },
          "source": "Practice-specific facilities and security incident-response procedure (equipment breakdown, plumbing failure, gas-line leak, break-in, robbery, credential theft, lost access control, unauthorized-person response); no single federal or Cal/OSHA standard in this citation governs this bundle — Practice policy — no published authority governs this step."
        },
        {
          "kind": "public_domain",
          "label": "No single authority covers mold + asbestos + lead-paint discovery in an existing dental office as one claim — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single authority covers mold + asbestos + lead-paint discovery in an existing dental office as one claim — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Checked the two candidate anchors directly: 29 CFR §1926.1101's own scope clause is construction-industry only (\"regulates asbestos exposure in ... construction, alteration, repair, maintenance, or renovation of structures that contain asbestos\") — wrong regime for an occupied office that is not under construction. 29 CFR §1910.1001 is the general-industry counterpart and would be the closer OSHA asbestos anchor for an occupied suite, but the underlying protocol's claim bundles mold and lead-paint into the same sentence, and neither of those is an OSHA asbestos standard at all — mold has no hazard-specific OSHA standard (General Duty Clause territory only) and lead-based paint disturbance is primarily an EPA RRP (40 CFR Part 745) concern, not OSHA. No single citation carries all three hazards named in fuf-020's claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSH Act §5(a)(1) General Duty Clause; 29 CFR §1926.1101 (asbestos, construction/remediation)",
              "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1001"
            }
          },
          "source": "No single authority covers mold + asbestos + lead-paint discovery in an existing dental office as one claim — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "fuf-020",
      "kind": "operational",
      "materials": [
        "certified environmental testing lab contact",
        "OSHA Hazard Communication (1910.1200) reference for staff notification",
        "abatement contractor licensed for the suspected material",
        "signage to close off the affected area",
        "building age/construction records if available (for lead/asbestos likelihood)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Post signage, close the door, and move any patients or staff out of the room. Do not disturb the material further (no sanding, scraping or vacuuming suspected asbestos or lead paint).\n\nWhy: Disturbing suspected mold, asbestos or lead paint before testing can spread contamination and create an exposure the practice cannot later contain.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Close off and stop work in the affected area immediately",
          "why": "Disturbing suspected mold, asbestos or lead paint before testing can spread contamination and create an exposure the practice cannot later contain."
        },
        {
          "detail": "The practice owner (or delegated compliance officer) confirms the room stays closed to patient care until certified testing results come back.\n\nWhy: Reopening a potentially contaminated treatment room before results are known trades a scheduling inconvenience for an unknown exposure risk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: No patient care resumes in the affected area until testing clears it.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "practice-owner",
          "title": "No patient care resumes in the affected area until testing clears it",
          "why": "Reopening a potentially contaminated treatment room before results are known trades a scheduling inconvenience for an unknown exposure risk."
        },
        {
          "detail": "Tell staff what was found, where, and that the area is off-limits pending testing, per OSHA hazard-communication practice.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify all staff of the finding and the closed area"
        },
        {
          "detail": "Schedule sampling for the suspected material (mold air/surface sample, asbestos bulk sample, or lead paint XRF/lab test) before any remodel work resumes.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Engage a certified environmental testing lab"
        },
        {
          "detail": "Weigh whether the affected area is isolated (e.g. a single operatory or storage closet) versus connected to shared HVAC or plumbing that could carry contamination further.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "continue-other-rooms",
              "label": "Other rooms are unaffected — continue seeing patients elsewhere in the suite"
            },
            {
              "goto": "s6",
              "id": "close-suite",
              "label": "Shared HVAC or uncertain scope — close the full suite until results are known"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide whether other rooms can operate normally during testing"
        },
        {
          "detail": "Typical turnaround for mold, asbestos or lead testing is several business days; do not resume work in the area or guess at the result.",
          "id": "s6",
          "kind": "timer",
          "role": "practice-owner",
          "timer_seconds": 259200,
          "title": "Wait for certified lab results"
        },
        {
          "detail": "Weigh the confirmed material and concentration against licensed-abatement-contractor requirements in the jurisdiction.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "abate",
              "label": "Positive result — engage a licensed abatement contractor before reopening the area"
            },
            {
              "goto": "s8",
              "id": "clear",
              "label": "Negative result — clean and reopen the area normally"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide next steps based on lab results"
        },
        {
          "detail": "Confirm clearance testing (post-abatement, if abatement occurred) or the original negative result before returning the room to the schedule.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner signs off before the room returns to patient care.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner signs off before the room returns to patient care"
        },
        {
          "detail": "Record discovery date, material suspected/confirmed, testing lab and results, abatement contractor if used, and reopening date in the facility incident log.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Environmental incident closed out",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Environmental incident closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Mold, asbestos or lead-paint discovered in the suite — Water damage reveals mold, or a remodel disturbs suspected asbestos or lead paint.",
      "title": "Mold, asbestos or lead-paint discovered in the suite",
      "trigger": "Water damage reveals mold, or a remodel disturbs suspected asbestos or lead paint",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030(d)(4)(iii) regulated waste containment; Hazard Communication 1910.1200",
          "source": "OSHA 29 CFR 1910.1030(d)(4)(iii) regulated waste containment; Hazard Communication 1910.1200",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "fuf-021",
      "kind": "operational",
      "materials": [
        "biohazard spill kit (absorbent, disinfectant, gloves, barrier gown, eye protection)",
        "wet floor / closed sign",
        "regulated-waste bag or sharps container if applicable",
        "hand hygiene supplies"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "assistant",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Place a wet floor or closed sign, and redirect patients away from the spot until it is cleaned.\n\nWhy: Body fluid on a walking surface is both an infection risk and a slip hazard.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Cordon off the area immediately",
          "why": "Body fluid on a walking surface is both an infection risk and a slip hazard."
        },
        {
          "detail": "Offer a private space, water, and paper towels if needed. Note whether the person appears ill enough to need medical attention rather than just an accident.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Check on and reassure the patient or child involved"
        },
        {
          "detail": "Vomit and urine are cleaned with standard precautions; visible blood requires the regulated-waste protocol (barrier PPE, red-bag disposal per OSHA bloodborne pathogens standard).",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "blood-present",
              "label": "Blood is visible — use full bloodborne-pathogen precautions and regulated-waste disposal"
            },
            {
              "goto": "s4",
              "id": "no-blood",
              "label": "No blood — standard PPE and general cleanup"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Decide whether visible blood is present, changing the cleanup protocol"
        },
        {
          "detail": "Don gloves (and gown/eye protection if blood is present), absorb the material, disinfect the surface per label contact time, and dispose of waste in the appropriate bag (regulated-waste if blood was present).\n\nWhy: Following label contact time is what actually disinfects the surface — wiping it up alone does not.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Clean and disinfect using the biohazard spill kit",
          "why": "Following label contact time is what actually disinfects the surface — wiping it up alone does not."
        },
        {
          "detail": "Doff gloves and any gown/eye protection using proper technique, then wash hands before resuming other duties.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Remove PPE and perform hand hygiene"
        },
        {
          "detail": "Confirm the disinfectant's full contact time has passed and the floor is dry before removing the wet floor sign.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Remove the cordon once the surface is dry and clear"
        },
        {
          "detail": "Record time, location, whether blood was present, who cleaned it, and waste disposal method in the facility incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Cleanup closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Cleanup closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Vomit, urine or blood in the reception area or restroom — A patient or child is sick in the waiting room or a restroom needs biohazard cleanup.",
      "title": "Vomit, urine or blood in the reception area or restroom",
      "trigger": "A patient or child is sick in the waiting room or a restroom needs biohazard cleanup",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA physical safeguards 45 CFR 164.310",
          "source": "HIPAA physical safeguards 45 CFR 164.310"
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR §1301.76(b) (practitioners) / §1301.74(c) (non-practitioners) — controlled-substance theft/loss notification only",
          "repaired": {
            "action": "reduce",
            "evidence": "'21 CFR 1301.76(b) requires registrants to notify the Field Division Office of the DEA in their area, in writing, of the theft or significant loss of any controlled substances within one business day of discovery of such loss or theft.' Similarly, '21 CFR 1301.74(c) requires non-practitioners to preliminarily notify their local DEA Field Division Office, in writing, of the theft or significant loss of any controlled substances within one business day of discovering such theft or loss.' (eCFR / DEA Diversion Control, via search.)",
            "ticket": "PROT-017",
            "was": {
              "source": "DEA 21 CFR 1301.74–1301.76 (security, theft/loss report within one business day)",
              "url": null
            }
          },
          "source": "21 CFR §1301.76(b) and §1301.74(c) (theft/significant-loss notification to the DEA Field Division Office within one business day of discovery). Scope: applies only when the underlying incident IS a theft or significant loss of controlled substances — does NOT reach a generic after-hours alarm call (fuf-017), generic vandalism/property damage (fuf-018), a generic camera-footage request (fuf-019), or generic after-hours cleaning-crew access (fuf-022) unless controlled substances were actually stolen or lost as part of that event.",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.76"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "fuf-022",
      "kind": "operational",
      "materials": [
        "janitorial service contract",
        "confidentiality / business-associate-style agreement template",
        "access log (who holds keys/codes and when)",
        "list of restricted areas (records, drug storage, server closet)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the contract names the cleaning company, scope of areas to be cleaned, and insurance/liability coverage.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the janitorial contract before granting access"
        },
        {
          "detail": "Records storage, drug storage, and the server/network closet should be locked or excluded from the cleaning scope unless a staff member is present.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify and physically restrict areas the cleaning crew should not access"
        },
        {
          "detail": "The cleaning company signs a confidentiality/access agreement covering what they may see incidentally (screens left on, papers on desks) before receiving any key or alarm code.\n\nWhy: A vendor with unsupervised after-hours access to the suite is a privacy exposure unless the confidentiality expectation is documented in advance.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confidentiality agreement signed before keys or codes are issued.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confidentiality agreement signed before keys or codes are issued",
          "why": "A vendor with unsupervised after-hours access to the suite is a privacy exposure unless the confidentiality expectation is documented in advance."
        },
        {
          "detail": "Lock computer screens, put charts and papers with patient information away, and confirm drug storage is locked before the cleaning crew arrives.\n\nWhy: A confidentiality agreement reduces but does not eliminate incidental-exposure risk — staff habits are the first control.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Remind clinical and front-desk staff to secure charts, screens and drug logs before leaving",
          "why": "A confidentiality agreement reduces but does not eliminate incidental-exposure risk — staff habits are the first control."
        },
        {
          "detail": "Record who holds a key or alarm code, the date issued, and the expiration/review date, in the access log.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Issue and log the key or access code"
        },
        {
          "detail": "Weigh whether the practice already has a scheduled access audit or needs one added.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "add-audit",
              "label": "Add a quarterly reconciliation of everyone holding a key, badge or alarm code"
            },
            {
              "goto": "s7",
              "id": "existing-audit",
              "label": "Fold this vendor into an existing access-audit cadence"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Set the recurring audit for key/code holders"
        },
        {
          "detail": "Record contract start date, confidentiality agreement on file, restricted areas confirmed, and next audit date in the vendor access file.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the onboarding"
        },
        {
          "detail": "Cleaning-crew access onboarding closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Cleaning-crew access onboarding closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "After-hours cleaning crew access, keys and confidentiality — A janitorial contract starts or changes, or cleaners are found with access to records or drug areas.",
      "title": "After-hours cleaning crew access, keys and confidentiality",
      "trigger": "A janitorial contract starts or changes, or cleaners are found with access to records or drug areas",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol5/xml/CFR-2024-title29-vol5-sec1910-38.xml"
        },
        {
          "kind": "generic",
          "label": "State elevator safety code and local building/fire code — trapped-elevator response only",
          "repaired": {
            "action": "reduce",
            "evidence": "Elevator entrapment response (notify building management/elevator maintenance contractor, keep occupants calm, do not attempt self-extraction) is the subject matter state elevator safety codes and local building/fire codes actually regulate; alarm-monitoring calls, exterior vandalism, a restraining-order subject's appearance, and parking-lot personnel safety are security/HR incident types with no code provision cited or found to govern them.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic)",
              "url": null
            }
          },
          "source": "State elevator safety code and local building/fire code. Scope: fuf-007 (patient or staff trapped in the building elevator) only — does NOT reach fuf-017 (after-hours alarm/monitoring call), fuf-018 (vandalism/graffiti/property damage), fuf-023 (banned individual/restraining-order subject appears), or fuf-024 (staff parking-lot safety after dark), which are security/personnel-safety matters with no elevator, building, or fire-code content."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "fuf-023",
      "kind": "operational",
      "materials": [
        "banned-individual / restraining-order list with photo if available",
        "police non-emergency and 911 lines",
        "front-desk panic button or code phrase, if installed",
        "copy of any active protective order on file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk",
        "practice-owner",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the individual is aggressive, armed, or violating an active protective order in a threatening way, call 911 immediately before anything else — do not attempt to confront or detain them.\n\nWhy: A banned individual or restraining-order violation can escalate to violence in seconds; police response takes priority over any office process.",
          "gate": {
            "ack": "I confirm I have completed this step as written: If there is any immediate threat, call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "If there is any immediate threat, call 911 first",
          "why": "A banned individual or restraining-order violation can escalate to violence in seconds; police response takes priority over any office process."
        },
        {
          "detail": "Use the pre-agreed code phrase or button so coworkers are aware without alerting or provoking the individual.\n\nWhy: A visible reaction can escalate a tense situation before help arrives.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Alert other staff quietly using the office's established code phrase or panic signal",
          "why": "A visible reaction can escalate a tense situation before help arrives."
        },
        {
          "detail": "Check against the list maintained for this purpose; do not rely on memory alone if a photo or description is on file.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the person matches the banned-individual or protective-order record"
        },
        {
          "detail": "Weigh whether the individual can be calmly asked to leave versus whether police involvement is already warranted.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "ask-to-leave",
              "label": "Calmly and from a safe distance, ask the individual to leave the premises"
            },
            {
              "goto": "s5",
              "id": "call-police-nonemergency",
              "label": "No immediate threat but the person will not leave — call police non-emergency for a trespass response"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide how to address the situation once confirmed"
        },
        {
          "detail": "Keep the entrance area visible; do not let other staff go outside alone to check.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Monitor until the individual leaves the property"
        },
        {
          "detail": "If the situation involves a restraining order protecting a specific employee, confirm that employee is safe and offer to arrange a safe route home or a schedule change.\n\nWhy: The person at the center of the protective order carries the most direct risk and needs a direct, private check-in, not just a general staff notice.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Notify and check on the staff member or patient the individual targeted, if applicable.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Notify and check on the staff member or patient the individual targeted, if applicable",
          "why": "The person at the center of the protective order carries the most direct risk and needs a direct, private check-in, not just a general staff notice."
        },
        {
          "detail": "Record time, description of what happened, whether police were called, and any follow-up (updated banned list, protective order copy on file) in the security incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Incident closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Incident closed out"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Banned individual or restraining-order subject appears at the office — A dismissed patient, terminated employee or an employee's abuser subject to a protective order enters or lingers outside.",
      "title": "Banned individual or restraining-order subject appears at the office",
      "trigger": "A dismissed patient, terminated employee or an employee's abuser subject to a protective order enters or lingers outside",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title29-vol5/xml/CFR-2024-title29-vol5-sec1910-38.xml"
        },
        {
          "kind": "generic",
          "label": "State elevator safety code and local building/fire code — trapped-elevator response only",
          "repaired": {
            "action": "reduce",
            "evidence": "Elevator entrapment response (notify building management/elevator maintenance contractor, keep occupants calm, do not attempt self-extraction) is the subject matter state elevator safety codes and local building/fire codes actually regulate; alarm-monitoring calls, exterior vandalism, a restraining-order subject's appearance, and parking-lot personnel safety are security/HR incident types with no code provision cited or found to govern them.",
            "ticket": "PROT-017",
            "was": {
              "source": "State elevator safety code and local building/fire code (generic)",
              "url": null
            }
          },
          "source": "State elevator safety code and local building/fire code. Scope: fuf-007 (patient or staff trapped in the building elevator) only — does NOT reach fuf-017 (after-hours alarm/monitoring call), fuf-018 (vandalism/graffiti/property damage), fuf-023 (banned individual/restraining-order subject appears), or fuf-024 (staff parking-lot safety after dark), which are security/personnel-safety matters with no elevator, building, or fire-code content."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 15,
      "frequency": "per-shift",
      "id": "fuf-024",
      "kind": "operational",
      "materials": [
        "exterior lighting checked as part of closing checklist",
        "buddy-system closing pairing schedule",
        "phone with charge for staff walking to their cars",
        "police non-emergency line"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the entrance, walkway and parking area lights as part of the closing checklist; report any outage to the building manager.\n\nWhy: Poor lighting is the single biggest, most fixable factor in parking-lot safety incidents.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm exterior lighting is working before the last staff member leaves",
          "why": "Poor lighting is the single biggest, most fixable factor in parking-lot safety incidents."
        },
        {
          "detail": "No staff member walks to their car alone after dark if another closing staff member is available; walk out together and wait until each person is safely in their vehicle.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Use the buddy system for closing departures after dark"
        },
        {
          "detail": "Weigh whether anything happened during closing that needs an immediate response versus a routine closing with nothing to report.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "routine-closing",
              "label": "Routine closing, nothing to report"
            },
            {
              "goto": "s6",
              "id": "incident-occurred",
              "label": "An incident occurred (confrontation, break-in, suspicious person)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was there a confrontation or a break-in in the lot tonight?"
        },
        {
          "detail": "Record lighting check status, whether the buddy system was used, and any incident detail and police report number, in the closing/security log.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the closing shift"
        },
        {
          "detail": "Closing-shift safety routine complete",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Closing-shift safety routine complete"
        },
        {
          "detail": "If a staff member was confronted, threatened, or a vehicle was broken into, call police (911 if the person is still present or a threat is ongoing; non-emergency otherwise) before documenting.\n\nWhy: A parking-lot incident affecting staff safety is not something to handle informally the next morning.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Any confrontation or threat gets a police call, not just a note in the log.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Any confrontation or threat gets a police call, not just a note in the log",
          "why": "A parking-lot incident affecting staff safety is not something to handle informally the next morning."
        },
        {
          "detail": "Follow up the next business day (or immediately, if the incident is severe) to confirm the staff member is safe and ask whether they need time off, an escort going forward, or other support.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Check on the affected staff member and offer support"
        }
      ],
      "subclass": "facility-utility-and-security-incidents",
      "summary": "Staff safety leaving after dark and parking-lot incident — Closing staff leave after dark, or a car break-in or confrontation happens in the lot.",
      "title": "Staff safety leaving after dark and parking-lot incident",
      "trigger": "Closing staff leave after dark, or a car break-in or confrontation happens in the lot",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR guidance on right of access and risk analysis",
          "source": "HHS OCR guidance on right of access and risk analysis",
          "url": "https://www.hhs.gov/hipaa/for-professionals/index.html"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.520 — Notice of Privacy Practices content and distribution requirements",
          "source": "45 CFR 164.520 — Notice of Privacy Practices content and distribution requirements",
          "url": "https://www.ecfr.gov/current/title-45/section-164.520"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "hip-001",
      "kind": "compliance",
      "materials": [
        "current Notice of Privacy Practices (paper and digital copy)",
        "acknowledgment form",
        "lobby posting frame",
        "practice management system record flag"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Is this a first visit, or has the notice changed since the patient's last acknowledgment?\n\nWhy: The notice only needs to be re-delivered when it is new to the patient or the content has changed.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "first-visit",
              "label": "First visit for this patient"
            },
            {
              "goto": "s2",
              "id": "revised-notice",
              "label": "Notice was revised since the patient last acknowledged one"
            },
            {
              "goto": "s5",
              "id": "no-change",
              "label": "Returning patient, notice unchanged since last acknowledgment"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this a first visit, or has the notice changed since the patient's last acknowledgment?",
          "why": "The notice only needs to be re-delivered when it is new to the patient or the content has changed."
        },
        {
          "detail": "Give the patient a paper or digital copy of the current notice and offer a moment to read it before continuing check-in.\n\nWhy: 45 CFR 164.520 requires the notice be provided no later than the first service delivery date.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand the patient the current Notice of Privacy Practices",
          "why": "45 CFR 164.520 requires the notice be provided no later than the first service delivery date."
        },
        {
          "detail": "Does the patient sign the written acknowledgment?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "signed",
              "label": "Patient signs the acknowledgment"
            },
            {
              "goto": "s8",
              "id": "declines",
              "label": "Patient declines or is unable to sign"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient sign the written acknowledgment?"
        },
        {
          "detail": "File the signed acknowledgment form in the patient's chart with the delivery date noted.\n\nRecord: Scanned or original signed acknowledgment attached to the patient's chart with the date of delivery.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "File the signed acknowledgment in the patient record"
        },
        {
          "detail": "Check: paper copy visible at the front desk or waiting area; current version posted on the practice website; digital intake copy matches the posted version; effective date is current.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the notice is posted and current everywhere it is required"
        },
        {
          "detail": "Set a reminder to re-check the notice content and posting locations at the practice's chosen cadence, or immediately when a policy that the notice describes changes.\n\nCadence: 0 minute(s) (no valid timer duration in source — downgraded from a timer step).",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the next periodic accuracy review"
        },
        {
          "detail": "Notice delivery and posting confirmed",
          "id": "s7",
          "kind": "step",
          "title": "Notice delivery and posting confirmed"
        },
        {
          "detail": "Note in the chart that the notice was offered, the reason it was not signed, and that treatment was not conditioned on signing.\n\nWhy: 45 CFR 164.520(c) permits proceeding with treatment when a good-faith effort is documented even if the patient does not sign.\n\nRecord: Good-faith-effort note with date and reason in the patient chart.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Document a good-faith effort to obtain acknowledgment",
          "why": "45 CFR 164.520(c) permits proceeding with treatment when a good-faith effort is documented even if the patient does not sign."
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Notice of Privacy Practices — first-visit delivery, acknowledgment and posting — A new patient checks in for a first visit, the notice is revised, or the website or lobby copy is out of date.",
      "title": "Notice of Privacy Practices — first-visit delivery, acknowledgment and posting",
      "trigger": "A new patient checks in for a first visit, the notice is revised, or the website or lobby copy is out of date",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR guidance on right of access and risk analysis",
          "source": "HHS OCR guidance on right of access and risk analysis",
          "url": "https://www.hhs.gov/hipaa/for-professionals/index.html"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.308(a)(1) — Security Management Process, required risk analysis and risk management",
          "source": "45 CFR 164.308(a)(1) — Security Management Process, required risk analysis and risk management",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 240,
      "frequency": "annual",
      "id": "hip-002",
      "kind": "compliance",
      "materials": [
        "asset inventory (systems, devices, cloud services holding PHI)",
        "prior risk analysis document",
        "risk analysis worksheet or template",
        "risk management plan tracker"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "it-vendor",
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "List every system, device, application and vendor that stores, processes or transmits PHI: practice management system, imaging, email, cloud storage, backup, mobile devices, and any AI or analytics tool in use.\n\nWhy: 45 CFR 164.308(a)(1) risk analysis must cover the full scope of where ePHI lives, not just the primary system.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the inventory of systems and devices that hold or transmit PHI",
          "why": "45 CFR 164.308(a)(1) risk analysis must cover the full scope of where ePHI lives, not just the primary system."
        },
        {
          "detail": "For each item in the inventory, note plausible threats (lost device, phishing, unpatched software, unauthorized access, unencrypted transmission) and existing safeguards already in place.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Identify reasonably anticipated threats and vulnerabilities for each asset"
        },
        {
          "detail": "Score each threat/vulnerability pair using the practice's risk scale (for example likelihood × impact) and record the resulting risk level per asset.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Rate likelihood and impact for each identified risk"
        },
        {
          "detail": "For every risk rated moderate or higher, write a remediation action, an owner, and a target completion date.\n\nWhy: The risk analysis alone is not enough — 164.308(a)(1) requires an accompanying risk management process that reduces identified risks to a reasonable level.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the risk management plan addressing each identified risk",
          "why": "The risk analysis alone is not enough — 164.308(a)(1) requires an accompanying risk management process that reduces identified risks to a reasonable level."
        },
        {
          "detail": "The practice owner reviews the completed risk analysis and management plan and signs to confirm resources will be allocated to the remediation items.\n\nWhy: Risk management decisions carry budget and liability consequences and need an accountable sign-off, not just staff-level completion.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews and signs off on the analysis and plan.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews and signs off on the analysis and plan",
          "why": "Risk management decisions carry budget and liability consequences and need an accountable sign-off, not just staff-level completion."
        },
        {
          "detail": "File the completed risk analysis, the risk management plan with owners and dates, and the practice owner's signed sign-off.\n\nRecord: Completed risk analysis document, risk management plan with owners and dates, and the practice owner's sign-off, retained per the practice's document retention schedule.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the analysis, plan and sign-off in the compliance record"
        },
        {
          "detail": "Confirm: each remediation item has an owner and target date entered into the tracker; a reminder is set for the annual re-analysis date; a trigger is noted to re-run this protocol early if a new system, vendor, or security incident occurs.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Set up tracking for open action items and the next cycle"
        },
        {
          "detail": "Risk analysis and management plan complete and filed",
          "id": "s8",
          "kind": "step",
          "title": "Risk analysis and management plan complete and filed"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Annual security risk analysis and risk management plan — The annual analysis date arrives, a new system or vendor touching PHI is adopted, or a security incident closes.",
      "title": "Annual security risk analysis and risk management plan",
      "trigger": "The annual analysis date arrives, a new system or vendor touching PHI is adopted, or a security incident closes",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.308(a)(5) — Security Awareness and Training standard",
          "source": "45 CFR 164.308(a)(5) — Security Awareness and Training standard",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.530(b) — Privacy Rule training requirement",
          "source": "45 CFR 164.530(b) — Privacy Rule training requirement",
          "url": "https://www.ecfr.gov/current/title-45/section-164.530"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "hip-003",
      "kind": "compliance",
      "materials": [
        "training module or slide deck covering Privacy, Security and Breach Notification Rules",
        "training sign-off log",
        "sanction policy summary",
        "role-specific access reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Which trigger applies?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-hire",
              "label": "New team member starting"
            },
            {
              "goto": "s8",
              "id": "annual-due",
              "label": "Annual refresher is due"
            },
            {
              "goto": "s9",
              "id": "policy-change",
              "label": "A policy materially changed"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "hr",
          "title": "Which trigger applies?"
        },
        {
          "detail": "Book the training session so it completes before the new hire is granted system access that reaches PHI.\n\nWhy: 45 CFR 164.530(b) requires training within a reasonable period after a person joins the workforce, and access controls in hip-006 depend on training being done first.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Schedule initial training before or on the first day handling PHI",
          "why": "45 CFR 164.530(b) requires training within a reasonable period after a person joins the workforce, and access controls in hip-006 depend on training being done first."
        },
        {
          "detail": "Cover: what counts as PHI, minimum necessary use, safe handling of records and devices, recognizing and reporting a suspected breach, and the practice's sanction policy for violations.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Deliver the training covering Privacy, Security and Breach Notification basics"
        },
        {
          "detail": "Ask staff to answer a handful of scenario questions or discuss how they would handle a few common situations to confirm the material was understood.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm understanding with a short quiz or discussion"
        },
        {
          "detail": "Log each attendee's name, training topic, completion date and trainer in the sign-off log.\n\nRecord: Attendee name, training topic, date completed, and trainer, entered into the training sign-off log retained for the practice's audit trail.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Log the completed training for each attendee"
        },
        {
          "detail": "Check: every new hire completed training before PHI access was granted; every active staff member's most recent sign-off is under 12 months old; anyone who missed the session has a makeup date scheduled.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm no gaps remain"
        },
        {
          "detail": "Workforce training cycle complete",
          "id": "s7",
          "kind": "step",
          "title": "Workforce training cycle complete"
        },
        {
          "detail": "Set the session date and notify staff whose last training sign-off is approaching 12 months old.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the annual refresher for all active staff"
        },
        {
          "detail": "Identify which roles are affected by the change and schedule a shorter session covering only the updated material.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule a targeted update session covering the changed policy"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Workforce HIPAA privacy and security training (hire, annual, after policy change) — A new team member starts, 12 months elapse, or a policy materially changes.",
      "title": "Workforce HIPAA privacy and security training (hire, annual, after policy change)",
      "trigger": "A new team member starts, 12 months elapse, or a policy materially changes",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.308(b) and 164.502(e) — business associate contracts required before disclosure of PHI to a business associate",
          "source": "45 CFR 164.308(b) and 164.502(e) — business associate contracts required before disclosure of PHI to a business associate",
          "url": "https://www.ecfr.gov/current/title-45/section-164.502"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "hip-004",
      "kind": "compliance",
      "materials": [
        "business associate agreement template",
        "vendor register",
        "vendor's proposed data-handling description"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Record which vendor is asking for access, what system or data category they would touch (records, images, billing data, an AI tool processing patient information), and why.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the vendor's request and what PHI access it would need"
        },
        {
          "detail": "Does a current, signed business associate agreement already cover this vendor and this scope of access?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "already-covered",
              "label": "A current BAA already covers this exact scope"
            },
            {
              "goto": "s5",
              "id": "not-covered",
              "label": "No BAA exists, or the existing one does not cover this scope"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does a current, signed business associate agreement already cover this vendor and this scope of access?"
        },
        {
          "detail": "Update the vendor register with the vendor name, access scope, BAA execution date and next review date.\n\nRecord: Vendor name, scope of PHI access, BAA execution date, and renewal or review date entered into the register.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the vendor and business associate register"
        },
        {
          "detail": "Vendor access authorized under an executed business associate agreement",
          "id": "s4",
          "kind": "step",
          "title": "Vendor access authorized under an executed business associate agreement"
        },
        {
          "detail": "Use the practice's BAA template, or review the vendor's proposed BAA, covering permitted uses, safeguards required, breach notification obligations, and termination handling of PHI.\n\nWhy: 45 CFR 164.502(e) prohibits disclosing PHI to a business associate without a written agreement meeting the Rule's content requirements.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft or obtain the business associate agreement",
          "why": "45 CFR 164.502(e) prohibits disclosing PHI to a business associate without a written agreement meeting the Rule's content requirements."
        },
        {
          "detail": "No vendor account, data feed, or system integration touching PHI is activated until the BAA is fully executed by both parties.\n\nWhy: This is the consequential step — granting access before signature creates a HIPAA violation the practice cannot undo after the fact.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner or compliance officer signs the BAA before any access is granted.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner or compliance officer signs the BAA before any access is granted",
          "why": "This is the consequential step — granting access before signature creates a HIPAA violation the practice cannot undo after the fact."
        },
        {
          "detail": "IT vendor is notified that the BAA is executed and provided with the minimum-necessary scope of access to configure.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand off to IT to provision the vendor's access"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Business associate agreement executed before any vendor touches PHI — A new vendor (IT, billing, shredding, cloud, AI tool, lab portal) requests access to patient information.",
      "title": "Business associate agreement executed before any vendor touches PHI",
      "trigger": "A new vendor (IT, billing, shredding, cloud, AI tool, lab portal) requests access to patient information",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.308(b) — ongoing oversight of business associate arrangements",
          "source": "45 CFR 164.308(b) — ongoing oversight of business associate arrangements",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "hip-005",
      "kind": "compliance",
      "materials": [
        "current vendor and business associate register",
        "copies of executed BAAs",
        "vendor security attestations if available"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "List every vendor on record with PHI access, their BAA execution date, and current access scope.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current vendor and business associate register"
        },
        {
          "detail": "For each vendor confirm: the BAA is still on file and current; the vendor is still actively used; the access scope on file matches what they actually access; contact information is current.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify each vendor's status"
        },
        {
          "detail": "Were any issues found?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean",
              "label": "All vendors current and accurate"
            },
            {
              "goto": "s7",
              "id": "issues-found",
              "label": "A vendor is inactive, unlisted, or has an expired BAA"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Were any issues found?"
        },
        {
          "detail": "Record the review date, vendors checked, issues found and remediation actions taken.\n\nRecord: Review date, vendors checked, issues found, and remediation actions taken, filed in the compliance record.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the completed annual review"
        },
        {
          "detail": "Set a reminder for next year's review date, and note that a vendor replacement or a vendor-reported breach should trigger an earlier ad hoc review.\n\nCadence: 0 minute(s) (no valid timer duration in source — downgraded from a timer step).",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the next annual review"
        },
        {
          "detail": "Vendor register review complete",
          "id": "s6",
          "kind": "step",
          "title": "Vendor register review complete"
        },
        {
          "detail": "Revoke access for inactive vendors, route missing or expired BAAs to hip-001 protocol (business associate agreement before vendor access), and correct register entries.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Remediate flagged vendors"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Business associate and vendor register annual review — The annual review date, a vendor is replaced, or a vendor reports a breach.",
      "title": "Business associate and vendor register annual review",
      "trigger": "The annual review date, a vendor is replaced, or a vendor reports a breach",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.514(d) — minimum necessary standard",
          "source": "45 CFR 164.514(d) — minimum necessary standard",
          "url": "https://www.ecfr.gov/current/title-45/section-164.514"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.308(a)(3) and (a)(4) — workforce security and access management standards",
          "source": "45 CFR 164.308(a)(3) and (a)(4) — workforce security and access management standards",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "quarterly",
      "id": "hip-006",
      "kind": "compliance",
      "materials": [
        "role-to-access mapping reference",
        "system access list per staff member",
        "access review checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Which trigger applies?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "role-change",
              "label": "A staff member's role changed"
            },
            {
              "goto": "s2",
              "id": "new-hire-access",
              "label": "A new hire needs access provisioned"
            },
            {
              "goto": "s6",
              "id": "quarterly-due",
              "label": "Quarterly review is due"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Which trigger applies?"
        },
        {
          "detail": "Use the role-to-access reference to determine exactly which system modules and record categories this role needs (for example front desk sees scheduling and demographics but not full clinical notes).\n\nWhy: 45 CFR 164.514(d) requires limiting access to the minimum necessary for the workforce member's function.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Map the role to its minimum-necessary access scope",
          "why": "45 CFR 164.514(d) requires limiting access to the minimum necessary for the workforce member's function."
        },
        {
          "detail": "IT vendor grants or revokes specific system permissions to match the mapped role scope, confirming training (hip-003) is already complete for a new hire before access is activated.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand off to IT to provision or adjust system access"
        },
        {
          "detail": "Record the staff member, role, access scope granted or corrected and the review date.\n\nRecord: Staff member, role, access scope granted or corrected, and review date, entered into the access tracking log.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the access assignment or review outcome"
        },
        {
          "detail": "Access assignment or quarterly review complete",
          "id": "s5",
          "kind": "step",
          "title": "Access assignment or quarterly review complete"
        },
        {
          "detail": "Export or list each staff member's current system permissions across all systems holding PHI.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current access list for every active staff member"
        },
        {
          "detail": "Check: each staff member's access matches their current role; no terminated employee still has active access; no one retains access from a prior role after a role change; any AI or analytics tool access is scoped to structural/de-identified data only where applicable.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compare each person's actual access against their current role's minimum-necessary scope"
        },
        {
          "detail": "Were any mismatches found?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean-review",
              "label": "All access matches current roles"
            },
            {
              "goto": "s9",
              "id": "mismatch-found",
              "label": "One or more mismatches found"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Were any mismatches found?"
        },
        {
          "detail": "IT vendor revokes excess access or adds missing access so each person's permissions match their current role.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand off corrections to IT"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Role-based access assignment and quarterly minimum-necessary access review — A staff role changes, a new hire needs system access, or the quarterly access review is due.",
      "title": "Role-based access assignment and quarterly minimum-necessary access review",
      "trigger": "A staff role changes, a new hire needs system access, or the quarterly access review is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR guidance on right of access and risk analysis",
          "source": "HHS OCR guidance on right of access and risk analysis",
          "url": "https://www.hhs.gov/hipaa/for-professionals/index.html"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.524 — right of access, 30-day timeline (one 30-day extension allowed with notice), reasonable cost-based fee",
          "source": "45 CFR 164.524 — right of access, 30-day timeline (one 30-day extension allowed with notice), reasonable cost-based fee",
          "url": "https://www.ecfr.gov/current/title-45/section-164.524"
        },
        {
          "kind": "statute",
          "label": "California Health & Safety Code §123110 — 15-day production of records for California patients",
          "source": "California Health & Safety Code §123110 — 15-day production of records for California patients",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=123110."
        },
        {
          "kind": "statute",
          "label": "California Confidentiality of Medical Information Act, Civil Code §56 et seq.",
          "source": "California Confidentiality of Medical Information Act, Civil Code §56 et seq.",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=56."
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hip-007",
      "kind": "compliance",
      "materials": [
        "records request/authorization form",
        "identity verification checklist",
        "fee schedule for copies",
        "secure transfer method (portal, encrypted email, mail)",
        "disclosure log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "compliance-officer",
        "patient",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note who is asking (patient, personal representative, another dental office, specialist, or insurer), what records are wanted, the requested delivery method, and the date received.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive and log the records request"
        },
        {
          "detail": "Confirm the requester is the patient, a legally authorized personal representative, or holds a valid signed authorization; for another office or insurer, confirm the request is on the patient's behalf with proper authorization on file.\n\nWhy: Releasing PHI to the wrong person is itself a privacy violation, so identity and authority are confirmed before any content moves.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify the identity and authority of the requester",
          "why": "Releasing PHI to the wrong person is itself a privacy violation, so identity and authority are confirmed before any content moves."
        },
        {
          "detail": "Is a signed authorization required and on file, or does an exception apply (patient requesting their own record)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "self-request",
              "label": "Patient requesting their own record"
            },
            {
              "goto": "s10",
              "id": "authorized-third-party",
              "label": "Valid signed authorization on file for a third party"
            },
            {
              "goto": "s11",
              "id": "no-authorization",
              "label": "No valid authorization on file for a third-party request"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a signed authorization required and on file, or does an exception apply (patient requesting their own record)?"
        },
        {
          "detail": "Compile the requested chart notes, treatment records, and radiographs in the requested format (paper copy, electronic file, or portal access) where the practice's systems support it.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather the requested records and radiographs"
        },
        {
          "detail": "Charge only a reasonable, cost-based fee for copying and, if applicable, mailing, per the practice's fee schedule; note that a patient's own record request cannot be denied for nonpayment of unrelated balances.\n\nWhy: 45 CFR 164.524 limits fees to reasonable cost-based amounts and prohibits conditioning access on an unrelated debt.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Apply the permitted fee, if any",
          "why": "45 CFR 164.524 limits fees to reasonable cost-based amounts and prohibits conditioning access on an unrelated debt."
        },
        {
          "detail": "Use the patient's chosen secure delivery method (encrypted portal, encrypted email, or mailed copy) matching what the practice can support.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Transfer the records through a secure method"
        },
        {
          "detail": "Check: fulfilled within 30 days of the request under HIPAA (one 30-day extension allowed with written notice to the requester); for California patients, fulfilled within 15 days per Health & Safety Code §123110; earlier deadline controls when both apply.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the fulfillment meets the applicable deadline"
        },
        {
          "detail": "Log the requester, records released, transfer method, fulfillment date and any fee charged.\n\nRecord: Requester, records released, method of transfer, date fulfilled, and any fee charged, entered into the disclosure log for accounting-of-disclosures purposes.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the disclosure"
        },
        {
          "detail": "Records request fulfilled and logged",
          "id": "s9",
          "kind": "step",
          "title": "Records request fulfilled and logged"
        },
        {
          "detail": "A named compliance officer confirms the authorization on file actually covers the specific records, radiographs and recipient requested before any content is gathered or transferred — self-requests by the patient about their own record do not need this gate.\n\nWhy: Releasing a full chart or radiograph set to a specialist, insurer, or another office is a consequential, non-reversible disclosure that needs a named sign-off distinct from the front-desk or office-manager staff who logged and screened the request.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms authorization scope before records move.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms authorization scope before records move",
          "why": "Releasing a full chart or radiograph set to a specialist, insurer, or another office is a consequential, non-reversible disclosure that needs a named sign-off distinct from the front-desk or office-manager staff who logged and screened the request."
        },
        {
          "detail": "Send the authorization form to the patient or their representative and hold the request until a valid signed authorization is returned.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Obtain a signed authorization before proceeding"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Patient right of access and records release — authorization, statutory timelines, permitted fees, transfer, disclosure log — A patient, personal representative, new dental office, specialist or insurer asks for copies of records or radiographs.",
      "title": "Patient right of access and records release — authorization, statutory timelines, permitted fees, transfer, disclosure log",
      "trigger": "A patient, personal representative, new dental office, specialist or insurer asks for copies of records or radiographs",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400–414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.526 — right to request amendment of PHI, 60-day response timeline (one 30-day extension allowed with notice)",
          "source": "45 CFR 164.526 — right to request amendment of PHI, 60-day response timeline (one 30-day extension allowed with notice)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.526"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hip-008",
      "kind": "compliance",
      "materials": [
        "amendment request form",
        "original chart entry",
        "amendment/addendum documentation template",
        "written response templates (accept/deny)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Ask the patient to state, in writing, which entry they believe is wrong and what correction they are requesting.\n\nWhy: 45 CFR 164.526 permits a covered entity to require the request in writing and to require a reason, so getting it in writing starts the clock and the record correctly.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the amendment request in writing",
          "why": "45 CFR 164.526 permits a covered entity to require the request in writing and to require a reason, so getting it in writing starts the clock and the record correctly."
        },
        {
          "detail": "The dentist who made or is responsible for the disputed entry reviews the original documentation and the patient's requested correction.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Route the request to the treating dentist for clinical review"
        },
        {
          "detail": "The dentist, as the licensed provider responsible for the clinical record, makes the determination to accept or deny the amendment based on whether the original entry is accurate and complete — never auto-decided by staff or by an AI tool.\n\nWhy: Accepting or denying a change to the clinical record is a licensed clinical judgment with downstream legal and treatment consequences, so it never proceeds without the treating dentist's explicit sign-off.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist determines whether the entry is accurate and complete.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist determines whether the entry is accurate and complete",
          "why": "Accepting or denying a change to the clinical record is a licensed clinical judgment with downstream legal and treatment consequences, so it never proceeds without the treating dentist's explicit sign-off."
        },
        {
          "detail": "Accept or deny the amendment?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accept",
              "label": "Accept — the entry was inaccurate or incomplete"
            },
            {
              "goto": "s8",
              "id": "deny",
              "label": "Deny — the entry is accurate and complete as written"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Accept or deny the amendment?"
        },
        {
          "detail": "Add the correction as a dated, attributed addendum linked to the original entry; the original entry is never deleted or altered so the record stays intact and auditable.\n\nWhy: 45 CFR 164.526 requires amendments to be made by appending or linking corrected information, not by deleting the original documentation.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Add the amendment as a linked addendum",
          "why": "45 CFR 164.526 requires amendments to be made by appending or linking corrected information, not by deleting the original documentation."
        },
        {
          "detail": "Send written notice to the patient confirming the amendment was made and who else, with the patient's agreement, will be notified.\n\nRecord: Written notice to the patient confirming the amendment, and identification of any others (with the patient's agreement, such as other providers who relied on the incorrect information) who should be notified of the correction.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the patient in writing that the amendment was made"
        },
        {
          "detail": "Amendment request resolved and documented",
          "id": "s7",
          "kind": "step",
          "title": "Amendment request resolved and documented"
        },
        {
          "detail": "Send a written denial stating the basis for denial, informing the patient of the right to submit a written statement of disagreement, and how to file a complaint.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Issue a written denial with the reason and the patient's rights"
        },
        {
          "detail": "File any patient statement of disagreement with the chart for inclusion in future disclosures.\n\nRecord: If the patient submits a statement of disagreement, it is filed with the chart and included with any future disclosure of the disputed information.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File any statement of disagreement with the chart"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Patient request to amend the record — A patient states an entry in their chart is wrong and asks for a change.",
      "title": "Patient request to amend the record",
      "trigger": "A patient states an entry in their chart is wrong and asks for a change",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.528 — accounting of disclosures of protected health information",
          "source": "45 CFR 164.528 — accounting of disclosures of protected health information",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.528"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR guidance on right of access and risk analysis",
          "source": "HHS OCR guidance on right of access and risk analysis",
          "url": "https://www.hhs.gov/hipaa/for-professionals/index.html"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hip-009",
      "kind": "compliance",
      "materials": [
        "disclosure log (electronic or paper)",
        "accounting-of-disclosures request form",
        "practice management system audit export"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record the date the patient (or personal representative) asked who has received their PHI. Verify identity with a photo ID or account-verification question before proceeding.\n\nWhy: 45 CFR 164.528 gives patients the right to an accounting, but the practice must confirm it is disclosing to the right person first.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the request and confirm identity",
          "why": "45 CFR 164.528 gives patients the right to an accounting, but the practice must confirm it is disclosing to the right person first."
        },
        {
          "detail": "Pass the dated request and identity confirmation to the compliance officer for processing within the six-year lookback window.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the compliance officer"
        },
        {
          "detail": "Export or retrieve every logged disclosure for this patient going back up to six years (or since the practice opened, if shorter), excluding disclosures for treatment, payment, and health-care operations, which are not required to be logged.\n\nWhy: 164.528 excludes TPO disclosures and a short list of others (e.g. to the patient themself, incident to a permitted use) from the accounting.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the disclosure log for the six-year period",
          "why": "164.528 excludes TPO disclosures and a short list of others (e.g. to the patient themself, incident to a permitted use) from the accounting."
        },
        {
          "detail": "Is the log complete for the period?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "complete",
              "label": "Log entries are complete and dated"
            },
            {
              "goto": "s8",
              "id": "gaps-found",
              "label": "Gaps found — a known disclosure was not logged"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the log complete for the period?"
        },
        {
          "detail": "For each qualifying disclosure list: date, recipient name and address (if known), a brief description of the information disclosed, and a brief statement of purpose. Group repetitive disclosures to the same recipient for the same purpose if permitted.\n\nWhy: This is the minimum content the Privacy Rule requires the accounting to contain.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compile the accounting document",
          "why": "This is the minimum content the Privacy Rule requires the accounting to contain."
        },
        {
          "detail": "Deliver the accounting to the patient within the required timeframe (no later than 60 days, one 30-day extension permitted with written notice to the patient) and log the date provided in the compliance tracker.\n\nRecord: compliance tracker entry: request date, response date, method of delivery, whether an extension was used",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Provide the accounting and record the response"
        },
        {
          "detail": "Request closed",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Request closed"
        },
        {
          "detail": "Reconstruct the missing disclosure entry from correspondence, fax logs, portal audit trails, or the recipient's own confirmation, and add it to the disclosure log with a note that it was backfilled and the date discovered.\n\nWhy: An incomplete accounting is itself a Privacy Rule finding; backfilling preserves accuracy for this and future requests.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Backfill the missing entry from source records",
          "why": "An incomplete accounting is itself a Privacy Rule finding; backfilling preserves accuracy for this and future requests."
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Accounting-of-disclosures request and disclosure log upkeep — A patient asks who has received their information, or a non-treatment/payment/operations disclosure occurs.",
      "title": "Accounting-of-disclosures request and disclosure log upkeep",
      "trigger": "A patient asks who has received their information, or a non-treatment/payment/operations disclosure occurs",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.522 — rights to request privacy protection for PHI (restrictions and confidential communications)",
          "source": "45 CFR 164.522 — rights to request privacy protection for PHI (restrictions and confidential communications)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.522"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hip-010",
      "kind": "compliance",
      "materials": [
        "restriction request form",
        "confidential communication preference form",
        "chart flag / alert field in the practice management system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What is the patient asking for?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "self-pay-restriction",
              "label": "Restrict disclosure to insurance for a self-paid item"
            },
            {
              "goto": "s7",
              "id": "confidential-comm",
              "label": "Confidential-communication preference (contact method)"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "What is the patient asking for?"
        },
        {
          "detail": "Confirm: (1) the item or service was paid in full out of pocket by the patient, (2) no insurance claim has already been submitted for it, (3) the patient is requesting the restriction in writing or on the practice's standard form.\n\nWhy: 164.522(a)(1)(vi) only guarantees this restriction right when the patient has paid in full and no claim has gone out yet — it is not a general right to block any billing.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Confirm the service qualifies for the restriction right",
          "why": "164.522(a)(1)(vi) only guarantees this restriction right when the patient has paid in full and no claim has gone out yet — it is not a general right to block any billing."
        },
        {
          "detail": "A named compliance officer or office manager reviews the self-pay confirmation and signs off before the chart flag is set, since an incorrect restriction can cause a downstream insurance-fraud or billing-accuracy problem.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before the restriction is applied.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before the restriction is applied"
        },
        {
          "detail": "Set a permanent flag on the specific line item in the billing system so it is excluded from any future insurance claim submission for this patient, and note the restriction date and staff who applied it.\n\nRecord: chart flag: restricted item, date restricted, staff initials",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Flag the chart and billing system"
        },
        {
          "detail": "Ensure the treating provider and billing staff who might otherwise submit the claim see the flag before any claim batch runs.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the clinical and billing teams of the restriction"
        },
        {
          "detail": "Preference or restriction applied",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Preference or restriction applied"
        },
        {
          "detail": "Record the patient's preferred alternate address, phone number, or method (e.g. call cell only, mail to a P.O. box) without requiring the patient to explain why.\n\nWhy: 164.522(b) requires accommodating reasonable confidential-communication requests without demanding a reason.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Capture the preferred contact method",
          "why": "164.522(b) requires accommodating reasonable confidential-communication requests without demanding a reason."
        },
        {
          "detail": "Set the preferred-contact flag in the practice management system so all future appointment reminders, statements, and outreach route through the requested channel only.\n\nRecord: chart flag: preferred contact method and date set",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the chart with the communication preference"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Restriction request and confidential-communication preference — A patient asks not to bill insurance for a self-paid service, or asks to be contacted only at a specific number or address.",
      "title": "Restriction request and confidential-communication preference",
      "trigger": "A patient asks not to bill insurance for a self-paid service, or asks to be contacted only at a specific number or address",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.530(d) — complaints to the covered entity",
          "source": "45 CFR 164.530(d) — complaints to the covered entity",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.530"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR — how to file a complaint / complaint process overview",
          "source": "HHS OCR — how to file a complaint / complaint process overview",
          "url": "https://www.hhs.gov/hipaa/filing-a-complaint/index.html"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hip-011",
      "kind": "compliance",
      "materials": [
        "privacy complaint intake form",
        "complaint log",
        "breach risk-assessment worksheet (hip-012, on standby)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "practice-owner",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Document exactly what the patient describes — what was disclosed, to whom, when, and how they learned of it — without arguing or minimizing, and thank them for reporting it.\n\nWhy: 164.530(d) requires the practice to accept and document privacy complaints; an accurate first account is the foundation for the investigation.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Take the complaint in the patient's own words",
          "why": "164.530(d) requires the practice to accept and document privacy complaints; an accurate first account is the foundation for the investigation."
        },
        {
          "detail": "Enter the complaint into the complaint log with a unique tracking number, date received, and the person assigned to investigate.\n\nRecord: complaint log: tracking number, date, description, assigned investigator",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the complaint"
        },
        {
          "detail": "Give the compliance officer the logged complaint and any supporting materials (misdirected mail, screenshot, witness names) for investigation.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the compliance officer"
        },
        {
          "detail": "Interview the staff involved, review any relevant chart access log, mail log, or posting, and determine the scope: how much information, about whom, seen or received by whom.\n\nWhy: The investigation determines both the facts for the patient's response and whether this crosses into a reportable breach.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Investigate what actually happened",
          "why": "The investigation determines both the facts for the patient's response and whether this crosses into a reportable breach."
        },
        {
          "detail": "Does this involve unsecured PHI disclosed outside permitted uses?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-phi-exposure",
              "label": "No PHI was actually exposed beyond permitted use, or it was fully secured (e.g. encrypted)"
            },
            {
              "goto": "s10",
              "id": "possible-breach",
              "label": "Unsecured PHI may have been impermissibly used or disclosed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does this involve unsecured PHI disclosed outside permitted uses?"
        },
        {
          "detail": "Explain what the investigation found, what corrective action was taken (retraining, process change, workstation relocation), and that no retaliation will occur for having complained.\n\nWhy: 45 CFR 164.530(g) prohibits retaliation against anyone who files a privacy complaint; saying so in writing closes that loop.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Prepare the written response to the patient",
          "why": "45 CFR 164.530(g) prohibits retaliation against anyone who files a privacy complaint; saying so in writing closes that loop."
        },
        {
          "detail": "The practice owner reviews and signs off on the response letter and any staff corrective action before it goes out, since sanctions or policy changes carry employment and liability consequences.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice-owner sign-off on the response and any corrective action.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice-owner sign-off on the response and any corrective action"
        },
        {
          "detail": "Record the resolution date, response summary, and any corrective action taken in the complaint log; retain for at least six years.\n\nRecord: complaint log: resolution date, summary, corrective action, retention flag",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the complaint in the log"
        },
        {
          "detail": "Complaint resolved and logged",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Complaint resolved and logged"
        },
        {
          "detail": "Open the breach discovery and four-factor risk assessment protocol (hip-012) using this complaint's investigation findings as the starting record; do not close this complaint until that assessment concludes.\n\nWhy: A privacy complaint can be the first sign of a reportable breach — the two processes must run together, not in place of each other.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escalate to the breach risk assessment protocol",
          "why": "A privacy complaint can be the first sign of a reportable breach — the two processes must run together, not in place of each other."
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Privacy complaint intake, investigation and response — A patient says their information was discussed in the lobby, mailed to the wrong address, or posted online.",
      "title": "Privacy complaint intake, investigation and response",
      "trigger": "A patient says their information was discussed in the lobby, mailed to the wrong address, or posted online",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.402 (definition of breach) and 164.404-164.408 (notification requirements and the four-factor risk assessment at 164.402(2))",
          "source": "45 CFR 164.402 (definition of breach) and 164.404-164.408 (notification requirements and the four-factor risk assessment at 164.402(2))",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-D"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR breach notification rule guidance",
          "source": "HHS OCR breach notification rule guidance",
          "url": "https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "hip-012",
      "kind": "compliance",
      "materials": [
        "breach risk-assessment worksheet (four-factor)",
        "incident log",
        "device inventory / encryption status list",
        "vendor business associate agreement file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner",
        "it-vendor",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Stop ongoing exposure first: remote-wipe or disable a lost device, disconnect a compromised workstation from the network, retrieve misdirected mail if possible, or ask a staff member to delete a social-media post.\n\nWhy: Containment limits the scope of exposure and must happen before or in parallel with the formal assessment — waiting for paperwork while data keeps leaking makes the eventual notification worse.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Contain the incident immediately",
          "why": "Containment limits the scope of exposure and must happen before or in parallel with the formal assessment — waiting for paperwork while data keeps leaking makes the eventual notification worse."
        },
        {
          "detail": "Record the exact date the incident was discovered (not the date it occurred, if different) — this date starts the 60-day notification clock.\n\nWhy: 164.404(a)(2) measures the 60-day deadline from discovery, so getting this date right is the single most consequence-bearing fact in the file.\n\nRecord: incident log: discovery date, description, who reported it",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the official discovery date",
          "why": "164.404(a)(2) measures the 60-day deadline from discovery, so getting this date right is the single most consequence-bearing fact in the file."
        },
        {
          "detail": "Is this an active security incident requiring IT emergency response (e.g. active ransomware)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "not-active-attack",
              "label": "Not an active attack — proceed to assessment"
            },
            {
              "goto": "s13",
              "id": "active-attack",
              "label": "Active attack in progress"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is this an active security incident requiring IT emergency response (e.g. active ransomware)?"
        },
        {
          "detail": "Identify the types of identifiers and the nature of the clinical information involved (e.g. name plus treatment plan versus name plus SSN and diagnosis) and the likelihood of re-identification.\n\nWhy: 45 CFR 164.402(2) sets this as the first of four factors in the presumption-of-breach risk assessment.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Factor 1 — nature and extent of the PHI involved",
          "why": "45 CFR 164.402(2) sets this as the first of four factors in the presumption-of-breach risk assessment."
        },
        {
          "detail": "Determine the unauthorized person who used the PHI or to whom it was disclosed, and whether that person has an independent legal obligation to protect it (e.g. another covered entity).\n\nWhy: A disclosure to another HIPAA-covered provider carries lower risk than one to an unknown third party — this is the second statutory factor.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Factor 2 — who received or could have accessed the information",
          "why": "A disclosure to another HIPAA-covered provider carries lower risk than one to an unknown third party — this is the second statutory factor."
        },
        {
          "detail": "Assess whether the information was actually viewed or acquired, or only potentially accessible — for example, a lost laptop that logs showed was never powered on versus one confirmed accessed.\n\nWhy: This factor distinguishes exposure risk from confirmed acquisition and materially changes the outcome.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Factor 3 — was the PHI actually acquired or viewed",
          "why": "This factor distinguishes exposure risk from confirmed acquisition and materially changes the outcome."
        },
        {
          "detail": "Note any mitigation: the device was encrypted per NIST-validated standards (making it 'secured PHI' and outside the breach definition), a signed confidentiality assurance was obtained from the recipient, or the data was remotely wiped before access.\n\nWhy: PHI that is encrypted to the HHS guidance standard is not 'unsecured PHI' and the incident may not be a reportable breach at all.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Factor 4 — was the risk mitigated",
          "why": "PHI that is encrypted to the HHS guidance standard is not 'unsecured PHI' and the incident may not be a reportable breach at all."
        },
        {
          "detail": "Write the specific conclusion the four factors support — low probability of compromise, or a reportable breach of unsecured PHI — with the reasoning for each factor, before it goes to the practice owner for sign-off.\n\nWhy: The owner's sign-off gate is only meaningful if it reviews a concrete written conclusion, not an undetermined set of factor notes with no recorded outcome yet.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the written four-factor determination",
          "why": "The owner's sign-off gate is only meaningful if it reviews a concrete written conclusion, not an undetermined set of factor notes with no recorded outcome yet."
        },
        {
          "detail": "The practice owner reviews and signs off on the compliance officer's drafted written determination — low probability of compromise, or a reportable breach — before route-outcome executes it and the file is closed or handed to the notification protocol, because the determination controls a legal notification obligation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance/owner sign-off on the breach determination.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Compliance/owner sign-off on the breach determination"
        },
        {
          "detail": "What does the documented four-factor assessment conclude?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "low-probability",
              "label": "Low probability of compromise — not a reportable breach"
            },
            {
              "goto": "s14",
              "id": "reportable-breach",
              "label": "Reportable breach of unsecured PHI"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What does the documented four-factor assessment conclude?"
        },
        {
          "detail": "File the completed four-factor worksheet, the discovery date, containment actions, and the signed determination in the incident log for at least six years.\n\nRecord: incident log: full worksheet, signed determination, retention flag",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the low-probability determination"
        },
        {
          "detail": "Assessment complete and filed",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Assessment complete and filed"
        },
        {
          "detail": "Hand off system isolation, forensic preservation, and restoration to the contracted IT vendor while the compliance officer continues the parallel risk assessment.",
          "id": "s13",
          "kind": "step",
          "role": "it-vendor",
          "title": "Escalate to the IT vendor for active-incident response"
        },
        {
          "detail": "Hand this completed risk-assessment file to the breach notification protocol (hip-013) to start individual, HHS, media (if applicable), and state notification timelines.",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escalate to the breach notification protocol"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Breach discovery — containment and four-factor risk assessment — Misdirected records, a lost device, a ransomware alert, a staff social-media post or a vendor breach notice is discovered.",
      "title": "Breach discovery — containment and four-factor risk assessment",
      "trigger": "Misdirected records, a lost device, a ransomware alert, a staff social-media post or a vendor breach notice is discovered",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.404 (notification to individuals), 164.406 (media notice for 500+), 164.408 (notice to HHS Secretary)",
          "source": "45 CFR 164.404 (notification to individuals), 164.406 (media notice for 500+), 164.408 (notice to HHS Secretary)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-D"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR breach portal for submitting notices to the Secretary",
          "source": "HHS OCR breach portal for submitting notices to the Secretary",
          "url": "https://ocrportal.hhs.gov/ocr/breach/wizard_breach.jsf"
        },
        {
          "kind": "statute",
          "label": "California data breach notification, Civil Code §1798.82",
          "source": "California data breach notification, Civil Code §1798.82",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=1798.82."
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "hip-013",
      "kind": "compliance",
      "materials": [
        "breach notification letter template",
        "affected-individual contact list",
        "HHS OCR breach portal access",
        "media contact list (500+ only)",
        "CA attorney general notification form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "The practice owner reviews the completed risk assessment (hip-012) and formally authorizes the notification process to begin, since sending breach notices is a consequential legal and reputational act that must not be initiated on staff judgment alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice-owner authorization to proceed with notification.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice-owner authorization to proceed with notification"
        },
        {
          "detail": "Finalize the list of affected patients from the incident investigation, cross-checked against the chart or system involved, and record the total count — this number determines which notification tracks apply.\n\nWhy: The 500-person threshold changes the notification path (media notice and immediate HHS notice) under 164.406 and 164.408.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Determine the number of affected individuals",
          "why": "The 500-person threshold changes the notification path (media notice and immediate HHS notice) under 164.406 and 164.408."
        },
        {
          "detail": "Include: a brief description of what happened, the date of the breach and date of discovery, the types of information involved, steps the individual should take to protect themselves, what the practice is doing to investigate and mitigate, and a contact phone number.\n\nWhy: 45 CFR 164.404(c) lists the required content elements for the individual notice.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the individual notification letter",
          "why": "45 CFR 164.404(c) lists the required content elements for the individual notice."
        },
        {
          "detail": "Confirm for each affected individual: current mailing address on file, whether the patient previously agreed to electronic notice, and whether any address is known to be out of date (triggering substitute notice).",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm mailing readiness for every affected individual"
        },
        {
          "detail": "Mail (or email, only if the patient agreed in advance to electronic notice) the letters to every affected individual, dated no later than 60 calendar days after the discovery date logged in hip-012.\n\nWhy: 164.404(b) sets 60 days from discovery as the outer limit, without unreasonable delay — this is a hard statutory deadline.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Send notices by first-class mail within 60 days of discovery",
          "why": "164.404(b) sets 60 days from discovery as the outer limit, without unreasonable delay — this is a hard statutory deadline."
        },
        {
          "detail": "Was contact information insufficient or out of date for any individual?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "all-reached",
              "label": "All individuals reached by mail or email"
            },
            {
              "goto": "s11",
              "id": "substitute-notice-needed",
              "label": "Insufficient or out-of-date contact info for one or more individuals"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was contact information insufficient or out of date for any individual?"
        },
        {
          "detail": "Were 500 or more individuals (in one jurisdiction) affected?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "under-500",
              "label": "Fewer than 500 individuals affected"
            },
            {
              "goto": "s12",
              "id": "500-or-more",
              "label": "500 or more individuals in the same state or jurisdiction affected"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Were 500 or more individuals (in one jurisdiction) affected?"
        },
        {
          "detail": "Add this breach to the running log of sub-500 breaches for the calendar year; the practice must submit this log to HHS within 60 days after the end of the calendar year in which the breach was discovered.\n\nWhy: 164.408(b) allows annual, batched reporting for smaller breaches rather than immediate reporting.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log for the annual HHS notice (under 500)",
          "why": "164.408(b) allows annual, batched reporting for smaller breaches rather than immediate reporting."
        },
        {
          "detail": "File copies of every notice sent (individual, media, HHS, state), the dates sent, and proof of mailing or filing in the incident log for at least six years.\n\nRecord: incident log: notification file, dates, proof of delivery/filing, retention flag",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the completed notification file"
        },
        {
          "detail": "Notification obligations complete",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notification obligations complete"
        },
        {
          "detail": "For fewer than 10 individuals with insufficient contact info, use an alternate form of written notice, telephone, or other means. For 10 or more, post a notice on the practice's website home page for 90 days or provide notice in major print or broadcast media in the area, and include a toll-free number active for 90 days.\n\nWhy: 164.404(d) requires substitute notice when the standard notice cannot be delivered, scaled by how many individuals are affected.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Provide substitute notice",
          "why": "164.404(d) requires substitute notice when the standard notice cannot be delivered, scaled by how many individuals are affected."
        },
        {
          "detail": "Notify prominent media outlets serving the affected state or jurisdiction within 60 days of discovery, and submit the notice to the HHS Secretary via the OCR breach portal contemporaneously with the individual notices (i.e. without unreasonable delay, no later than 60 days).\n\nWhy: 164.406 and 164.408(a) require immediate HHS filing and media notice specifically at the 500-or-more threshold, unlike the sub-500 track.",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify prominent media and HHS without delay",
          "why": "164.406 and 164.408(a) require immediate HHS filing and media notice specifically at the 500-or-more threshold, unlike the sub-500 track."
        },
        {
          "detail": "Were California residents among the 500+ affected?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "ca-not-involved",
              "label": "No California residents in the 500+ group"
            },
            {
              "goto": "s14",
              "id": "ca-residents-affected",
              "label": "California residents are among the affected individuals"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Were California residents among the 500+ affected?"
        },
        {
          "detail": "Submit notice to the California Attorney General's office when the breach affects more than 500 California residents, per Civil Code §1798.82, using the state's required notification form and content elements.\n\nWhy: California layers its own breach-notification statute on top of the federal HIPAA requirement; this addendum step is required in addition to, not instead of, the federal notices.",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the California Attorney General",
          "why": "California layers its own breach-notification statute on top of the federal HIPAA requirement; this addendum step is required in addition to, not instead of, the federal notices."
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Breach notification — individuals within 60 days, HHS, media if 500 or more, state attorney general (CA addendum) — The risk assessment concludes a reportable breach of unsecured PHI.",
      "title": "Breach notification — individuals within 60 days, HHS, media if 500 or more, state attorney general (CA addendum)",
      "trigger": "The risk assessment concludes a reportable breach of unsecured PHI",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.530(e) — sanctions for workforce members who fail to comply with privacy policies",
          "source": "45 CFR 164.530(e) — sanctions for workforce members who fail to comply with privacy policies",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.530"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "hip-014",
      "kind": "compliance",
      "materials": [
        "written sanctions policy",
        "audit-log excerpt showing the access in question",
        "employee personnel file",
        "sanctions documentation form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Record what was observed or reported (e.g. an audit-log hit showing a staff member opened a chart with no scheduled or billing reason, or a screenshot of PHI pasted into a public AI chat tool) and the date discovered.\n\nWhy: A specific, dated factual record is the basis for any sanction and protects both the practice and the employee from a vague accusation.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify and document the suspected violation",
          "why": "A specific, dated factual record is the basis for any sanction and protects both the practice and the employee from a vague accusation."
        },
        {
          "detail": "Did PHI leave the practice's control (e.g. pasted into a public tool, screenshotted off-site, shared externally)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "internal-only",
              "label": "Access stayed internal — no external exposure"
            },
            {
              "goto": "s9",
              "id": "external-exposure",
              "label": "PHI was disclosed or exposed outside the practice's control"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did PHI leave the practice's control (e.g. pasted into a public tool, screenshotted off-site, shared externally)?"
        },
        {
          "detail": "Give the employee an opportunity to explain the access or disclosure before any sanction is decided; document their response.\n\nWhy: Fair-process documentation protects the sanctions decision if it is later challenged and may surface a legitimate reason (e.g. covering for another provider) that changes the outcome.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Conduct a fact-finding interview with the employee",
          "why": "Fair-process documentation protects the sanctions decision if it is later challenged and may surface a legitimate reason (e.g. covering for another provider) that changes the outcome."
        },
        {
          "detail": "Apply the written sanctions policy's tiers (e.g. first unintentional minor violation = coaching and retraining; repeated or intentional violation = written warning or suspension; malicious or externally-exposing violation = termination) based on intent, harm, and prior history.\n\nWhy: 164.530(e) requires that sanctions be applied, but leaves the specific tiers to the practice's own written policy — consistency across employees is what makes the policy defensible.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Determine the sanctions tier",
          "why": "164.530(e) requires that sanctions be applied, but leaves the specific tiers to the practice's own written policy — consistency across employees is what makes the policy defensible."
        },
        {
          "detail": "The practice owner reviews and approves the proposed sanction, especially for suspension or termination, before it is communicated to the employee, since employment-consequence decisions carry legal exposure of their own.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice-owner approval before the sanction is delivered.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice-owner approval before the sanction is delivered"
        },
        {
          "detail": "Communicate the sanction to the employee in a private setting, have them sign an acknowledgment, and schedule any required retraining before they resume the access privileges involved.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Deliver the sanction and any required retraining"
        },
        {
          "detail": "File the signed acknowledgment, the interview notes, and the sanction applied in both the employee's personnel file and the compliance sanctions log, retained per the practice's record-retention schedule.\n\nRecord: personnel file + sanctions log: violation summary, interview notes, sanction applied, signed acknowledgment",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Document the sanction in the personnel file and compliance log"
        },
        {
          "detail": "Sanction applied and documented",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Sanction applied and documented"
        },
        {
          "detail": "Start the breach discovery and four-factor risk assessment protocol (hip-012) alongside this sanctions process — the employee's disciplinary consequence and the practice's notification obligation are separate tracks that both need to run.\n\nWhy: An internal privacy violation that exposes PHI externally (e.g. to an AI vendor with no BAA) can independently trigger the breach rule regardless of what discipline follows.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Open the breach risk assessment in parallel",
          "why": "An internal privacy violation that exposes PHI externally (e.g. to an AI vendor with no BAA) can independently trigger the breach rule regardless of what discipline follows."
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Applying the sanctions policy to a workforce privacy violation — An employee is found snooping in a chart, sharing a password, pasting a chart into a public AI tool, or posting patient information.",
      "title": "Applying the sanctions policy to a workforce privacy violation",
      "trigger": "An employee is found snooping in a chart, sharing a password, pasting a chart into a public AI tool, or posting patient information",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.312(b) — Security Rule audit controls standard",
          "source": "45 CFR 164.312(b) — Security Rule audit controls standard",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.312"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.308(a)(1)(ii)(D) — information system activity review, addressable implementation specification",
          "source": "45 CFR 164.308(a)(1)(ii)(D) — information system activity review, addressable implementation specification",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.308"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "hip-015",
      "kind": "compliance",
      "materials": [
        "practice management system audit-log export",
        "active-user access list",
        "prior month's review notes for comparison",
        "audit review checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Export the system's access log (who accessed which record, when, and what action was taken) for the review period from the practice management system and any other system holding PHI.\n\nWhy: 164.312(b) requires audit controls that record and examine activity in systems containing PHI; the export is the raw material for that examination.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Pull the audit log export for the review period",
          "why": "164.312(b) requires audit controls that record and examine activity in systems containing PHI; the export is the raw material for that examination."
        },
        {
          "detail": "Provide the audit log export and the current active-user access list to the compliance officer for review.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand the export to the compliance officer"
        },
        {
          "detail": "Look for: access to a patient chart by a staff member with no scheduling, billing, or clinical reason (e.g. a coworker, family member, VIP, or the staff member's own record); access outside normal working hours; a high volume of record views by one user in a short window; access by an account that should have been deactivated.\n\nWhy: These are the recognized patterns of inappropriate access ('snooping') that a routine review is designed to catch.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Screen the log for anomalous access",
          "why": "These are the recognized patterns of inappropriate access ('snooping') that a routine review is designed to catch."
        },
        {
          "detail": "Were any accesses flagged as potentially inappropriate?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-flags",
              "label": "No anomalies found this period"
            },
            {
              "goto": "s9",
              "id": "flags-found",
              "label": "One or more accesses flagged"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Were any accesses flagged as potentially inappropriate?"
        },
        {
          "detail": "Compare the system's active-user list to the current employee roster; confirm every separated employee's access was deactivated and every current employee's access level still matches their role.\n\nWhy: This review is also the recurring checkpoint for the minimum-necessary access control required elsewhere in the manual (hip-006) — separations are the most common source of stale access.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Reconcile the active-user list against current staff",
          "why": "This review is also the recurring checkpoint for the minimum-necessary access control required elsewhere in the manual (hip-006) — separations are the most common source of stale access."
        },
        {
          "detail": "Any access to deactivate or adjust?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-changes-needed",
              "label": "No access changes needed"
            },
            {
              "goto": "s11",
              "id": "changes-needed",
              "label": "One or more accounts need deactivation or adjustment"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Any access to deactivate or adjust?"
        },
        {
          "detail": "Log the review date, reviewer, any flagged items and their resolution, and any access changes made in the compliance audit-review file, retained for at least six years.\n\nRecord: audit-review log: review date, reviewer, flags, resolutions, access changes, retention flag",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the completed review"
        },
        {
          "detail": "Monthly review complete",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Monthly review complete"
        },
        {
          "detail": "A named compliance officer reviews the flagged audit-log entries and confirms they warrant escalation before the sanctions or complaint process is opened, since accusing a staff member of inappropriate access has employment consequences.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before escalating a flagged access.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before escalating a flagged access"
        },
        {
          "detail": "Open the sanctions policy protocol (hip-014) to investigate the flagged employee access, or the privacy complaint protocol (hip-011) if a patient raised the concern.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escalate flagged access for investigation"
        },
        {
          "detail": "Immediately deactivate access for separated employees or adjust permission levels to match the employee's current role, and confirm the change with a follow-up system check.",
          "id": "s11",
          "kind": "step",
          "role": "it-vendor",
          "title": "Deactivate or adjust the flagged accounts"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "System audit log and access review — The monthly log review, an employee separation, or a suspected inappropriate chart access.",
      "title": "System audit log and access review",
      "trigger": "The monthly log review, an employee separation, or a suspected inappropriate chart access",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C; Breach Notification Rule 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.512(g) — uses and disclosures about decedents to coroners and medical examiners",
          "source": "45 CFR 164.512(g) — uses and disclosures about decedents to coroners and medical examiners",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.512"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.512(f) — disclosures for law enforcement purposes",
          "source": "45 CFR 164.512(f) — disclosures for law enforcement purposes",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.512"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "hip-016",
      "kind": "compliance",
      "materials": [
        "official coroner/medical examiner or law-enforcement credential",
        "chain-of-custody log",
        "radiograph and chart duplication equipment",
        "disclosure log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Record who is asking (coroner, medical examiner, or law enforcement), the stated purpose (identifying remains or a missing person), and what records are requested (radiographs, chart, treatment history).",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the request and identify the type of requester"
        },
        {
          "detail": "Confirm: official government-issued identification or badge, a case or file number, the requesting agency's callback number verified independently (not the number given by the requester alone), and written request on agency letterhead where available.\n\nWhy: Verifying independently prevents a pretext caller from obtaining PHI by falsely claiming to be a coroner or investigator.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the requester's official credentials",
          "why": "Verifying independently prevents a pretext caller from obtaining PHI by falsely claiming to be a coroner or investigator."
        },
        {
          "detail": "Are the credentials verified and the purpose consistent with a permitted disclosure?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "verified",
              "label": "Credentials verified and purpose fits decedent-identification or law-enforcement disclosure"
            },
            {
              "goto": "s10",
              "id": "not-verified",
              "label": "Credentials cannot be verified or purpose is unclear"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Are the credentials verified and the purpose consistent with a permitted disclosure?"
        },
        {
          "detail": "Which permitted-disclosure basis applies?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "coroner-medical-examiner",
              "label": "Coroner or medical examiner identifying a decedent or determining cause of death"
            },
            {
              "goto": "s5",
              "id": "law-enforcement-purpose",
              "label": "Law enforcement identifying a missing person or investigating a crime"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Which permitted-disclosure basis applies?"
        },
        {
          "detail": "The treating dentist (or the compliance officer if the dentist is unavailable) reviews the request and confirms the records to be released before duplication and hand-off, since releasing a full clinical chart for identification purposes is a significant, non-reversible disclosure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating dentist or compliance officer sign-off before release.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating dentist or compliance officer sign-off before release"
        },
        {
          "detail": "Produce copies (never the original chart) of the specific radiographs and chart sections needed for identification, in the format requested (digital export preferred for radiographs).\n\nWhy: 45 CFR 164.512(g) permits disclosure to coroners and medical examiners for identifying a deceased person without patient authorization, but the practice still retains its own original records.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Duplicate the requested radiographs and chart",
          "why": "45 CFR 164.512(g) permits disclosure to coroners and medical examiners for identifying a deceased person without patient authorization, but the practice still retains its own original records."
        },
        {
          "detail": "Document who released the records, to whom, the date and time, the method of transfer, and the requester's signature acknowledging receipt.\n\nWhy: Forensic identification records may be used as evidence, so a documented chain of custody protects both the identification process and the practice.\n\nRecord: chain-of-custody log: releasing staff, recipient, date/time, method, recipient signature",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete a chain-of-custody log for the release",
          "why": "Forensic identification records may be used as evidence, so a documented chain of custody protects both the identification process and the practice."
        },
        {
          "detail": "Add this disclosure to the practice's disclosure log with the recipient, purpose, and date, since law-enforcement and decedent disclosures are not treatment/payment/operations and must be logged for future accounting-of-disclosures requests.\n\nRecord: disclosure log: recipient, purpose, date, legal basis cited",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the disclosure"
        },
        {
          "detail": "Records released and documented",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Records released and documented"
        },
        {
          "detail": "Tell the requester the practice cannot release records until credentials and purpose are independently confirmed, and provide a callback number for the practice; document the declined attempt.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Decline to release pending verification"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Coroner, medical examiner or law-enforcement request for dental records to identify remains — A coroner or investigator asks for radiographs and charts to identify a possible decedent or missing person.",
      "title": "Coroner, medical examiner or law-enforcement request for dental records to identify remains",
      "trigger": "A coroner or investigator asks for radiographs and charts to identify a possible decedent or missing person",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR guidance on minimum necessary and workforce access controls",
          "source": "HHS OCR guidance on minimum necessary and workforce access controls",
          "url": "https://www.hhs.gov/hipaa/for-professionals/index.html"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.308(a)(4) — information access management (role-based access, minimum necessary)",
          "source": "45 CFR 164.308(a)(4) — information access management (role-based access, minimum necessary)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        },
        {
          "kind": "statute",
          "label": "California Confidentiality of Medical Information Act, Civil Code §56 et seq.",
          "source": "California Confidentiality of Medical Information Act, Civil Code §56 et seq.",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=56."
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hip-017",
      "kind": "compliance",
      "materials": [
        "practice management system role-based access controls",
        "employee chart access restriction log",
        "sanction policy reference",
        "courtesy/discount policy document"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "dentist",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "When scheduling or intake reveals the patient is a current staff member or an immediate family member of one, flag the chart for restricted-access handling before the first clinical encounter.\n\nWhy: Minimum-necessary and access-management rules apply with extra force when the treating team and the patient's coworkers overlap.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the patient as an employee or an employee's family member",
          "why": "Minimum-necessary and access-management rules apply with extra force when the treating team and the patient's coworkers overlap."
        },
        {
          "detail": "Set role-based access so only the treating clinician, the assigned front-desk/billing staff handling that visit, and the compliance officer can open the chart; remove default all-staff visibility.\n\nWhy: Coworkers with routine system access but no treatment role have no minimum-necessary basis to view the chart.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Restrict practice management system access to the chart",
          "why": "Coworkers with routine system access but no treatment role have no minimum-necessary basis to view the chart."
        },
        {
          "detail": "Tell the assigned dentist or hygienist the chart is access-restricted and ask whether they want to recuse themselves (e.g. treating a supervisor or direct report) in favor of another provider.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the treating clinician of the restriction and any recusal option"
        },
        {
          "detail": "Does the treating clinician want to recuse from treating this employee or family member?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-recusal",
              "label": "Clinician proceeds as the treating provider"
            },
            {
              "goto": "s12",
              "id": "recuse",
              "label": "Clinician recuses; another provider is reassigned"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the treating clinician want to recuse from treating this employee or family member?"
        },
        {
          "detail": "Document the fee arrangement (if any) in an HR or billing file, not in the clinical chart, so financial terms do not become part of the treatment record.\n\nWhy: Keeps compensation/benefit information out of the PHI record while still creating an auditable business record.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Confirm any employee courtesy or discount terms in writing, separate from the clinical chart",
          "why": "Keeps compensation/benefit information out of the PHI record while still creating an auditable business record."
        },
        {
          "detail": "Compliance officer reviews the access list, recusal decision (if any), and courtesy documentation before the chart is used for the visit.\n\nWhy: A named compliance sign-off closes the loop so an employee chart is never left on default access by oversight.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer signs off on the restricted-access setup.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer signs off on the restricted-access setup",
          "why": "A named compliance sign-off closes the loop so an employee chart is never left on default access by oversight."
        },
        {
          "detail": "Write the restriction, access list, recusal decision and sign-off date into the access restriction log.\n\nRecord: Employee chart access restriction log entry: patient relationship to practice, access list, recusal decision, sign-off date.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the chart restriction and access list"
        },
        {
          "detail": "Wait until the practice's quarterly minimum-necessary access review cycle to audit who actually opened this chart.\n\nCadence: 0 minute(s) (no valid timer duration in source — downgraded from a timer step).",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hold until the next quarterly access-log review"
        },
        {
          "detail": "Checklist: (1) pull the system access log for the chart since restriction was applied; (2) confirm every viewer is on the approved list; (3) flag any unexplained view for follow-up; (4) confirm no export or print events outside the treating workflow.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Audit the chart's access log for out-of-role views"
        },
        {
          "detail": "Did the audit find an out-of-role access?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "clean",
              "label": "No out-of-role access found"
            },
            {
              "goto": "s13",
              "id": "found-access",
              "label": "An unauthorized or out-of-role view was found"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did the audit find an out-of-role access?"
        },
        {
          "detail": "Restricted-access setup confirmed and clean at quarterly review",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Restricted-access setup confirmed and clean at quarterly review"
        },
        {
          "detail": "Update the schedule and chart assignment to the substitute clinician and repeat the access restriction step for the new assignment.\n\nWhy: A comfortable, unpressured clinical relationship protects both care quality and the employee's privacy.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Reassign the visit to another available provider",
          "why": "A comfortable, unpressured clinical relationship protects both care quality and the employee's privacy."
        },
        {
          "detail": "Hand the finding to HR and the compliance officer jointly to apply the practice's sanction policy for impermissible access to PHI.",
          "id": "s13",
          "kind": "step",
          "role": "hr",
          "title": "Hand off to the workforce sanction process"
        },
        {
          "detail": "Restriction confirmed; sanction process opened for the access violation",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Restriction confirmed; sanction process opened for the access violation"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Treating team members and their families: chart access restriction and courtesy policy — An employee or their family member becomes a patient of the practice.",
      "title": "Treating team members and their families: chart access restriction and courtesy policy",
      "trigger": "An employee or their family member becomes a patient of the practice",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR guidance on confidential communications and restricted uses/disclosures",
          "source": "HHS OCR guidance on confidential communications and restricted uses/disclosures",
          "url": "https://www.hhs.gov/hipaa/for-professionals/index.html"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.522 — patient right to request restrictions on uses/disclosures and confidential communications",
          "source": "45 CFR 164.522 — patient right to request restrictions on uses/disclosures and confidential communications",
          "url": "https://www.ecfr.gov/current/title-45/section-164.522"
        },
        {
          "kind": "statute",
          "label": "California Confidentiality of Medical Information Act, Civil Code §56 et seq.",
          "source": "California Confidentiality of Medical Information Act, Civil Code §56 et seq.",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=56."
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hip-018",
      "kind": "compliance",
      "materials": [
        "practice management system alias/flag feature",
        "confidential-patient handling checklist",
        "media inquiry response script",
        "restricted access log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Does the patient request confidential handling, or does the practice identify a protective-order or safety need?\n\nWhy: A patient's own request for restricted communications or use is a right under 45 CFR 164.522; a protective order or known safety risk can also trigger the same handling proactively.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "patient-request",
              "label": "Patient requests confidential or restricted handling"
            },
            {
              "goto": "s2",
              "id": "safety-trigger",
              "label": "Practice identifies a protective order or public-figure safety concern"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient request confidential handling, or does the practice identify a protective-order or safety need?",
          "why": "A patient's own request for restricted communications or use is a right under 45 CFR 164.522; a protective order or known safety risk can also trigger the same handling proactively."
        },
        {
          "detail": "Ask the patient exactly what they want restricted (communications, disclosures to family, appearance on the schedule) and document their preference before applying any restriction.\n\nWhy: 45 CFR 164.522 rights belong to the patient; the practice implements what they ask for, not a generic template.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the patient's preferred handling and get it in writing.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm the patient's preferred handling and get it in writing",
          "why": "45 CFR 164.522 rights belong to the patient; the practice implements what they ask for, not a generic template."
        },
        {
          "detail": "Use the practice management system's confidential-patient flag or a coded initials-only entry so the patient's name and reason for visit are not visible on shared or printed schedules.\n\nWhy: Front-desk and other staff without a treatment role should not see who is coming in or why.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Apply an alias or coded entry in the appointment schedule",
          "why": "Front-desk and other staff without a treatment role should not see who is coming in or why."
        },
        {
          "detail": "Set role-based access in the practice management system so only the treating clinician and directly assigned support staff can open the chart; remove default all-staff visibility.\n\nWhy: Minimum-necessary access applies with extra weight when identity exposure itself is the risk.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Restrict chart access to the treating team only",
          "why": "Minimum-necessary access applies with extra weight when identity exposure itself is the risk."
        },
        {
          "detail": "Checklist: (1) do not call the patient's full name aloud in the waiting room; (2) keep the sign-in sheet free of the patient's real name or use a private check-in method; (3) seat the patient away from other patients if requested; (4) brief the treating team quietly before the visit rather than over a shared intercom.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Front-desk check-in and waiting-room handling"
        },
        {
          "detail": "Does a reporter, third party, or unrecognized caller ask to confirm the patient is or was seen at the practice?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-inquiry",
              "label": "No inquiry received"
            },
            {
              "goto": "s10",
              "id": "inquiry-received",
              "label": "An inquiry is received"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does a reporter, third party, or unrecognized caller ask to confirm the patient is or was seen at the practice?"
        },
        {
          "detail": "Write the patient's requested restrictions, alias convention, access list and start date into the restricted access log.\n\nRecord: Restricted access log entry: patient's requested restrictions, alias/coding convention used, access list, and date the flag was applied.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the active confidentiality flag and its terms"
        },
        {
          "detail": "Wait until the practice's periodic review point (e.g. next visit or annually) to reconfirm the patient still wants the restriction in place.\n\nCadence: 0 minute(s) (no valid timer duration in source — downgraded from a timer step).",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hold until the confidentiality flag's next scheduled reconfirmation"
        },
        {
          "detail": "Confidential handling confirmed and in effect for future visits",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confidential handling confirmed and in effect for future visits"
        },
        {
          "detail": "Use the standard script: state that the practice cannot confirm or deny that any named individual is a patient, and immediately notify the compliance officer of the inquiry.\n\nWhy: Confirming or denying patient status is itself a disclosure of PHI under HIPAA, even without releasing chart contents.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Decline to confirm or deny and escalate to the compliance officer",
          "why": "Confirming or denying patient status is itself a disclosure of PHI under HIPAA, even without releasing chart contents."
        },
        {
          "detail": "Write down the date, who asked, what they asked, and the no-confirm response given, in the inquiry log.\n\nRecord: Date, description of the inquiry, who made it (if known), and the exact response given, without confirming patient status.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the inquiry and the response given"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "High-profile or confidential patient: access restriction, alias and media guard — A public figure, local official or a patient under a protective order is scheduled.",
      "title": "High-profile or confidential patient: access restriction, alias and media guard",
      "trigger": "A public figure, local official or a patient under a protective order is scheduled",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C",
          "source": "HIPAA Privacy Rule 45 CFR 164 Subpart E; Security Rule Subpart C",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "HHS OCR guidance on individual choice for unencrypted communications and the security-vs-preference risk warning",
          "source": "HHS OCR guidance on individual choice for unencrypted communications and the security-vs-preference risk warning",
          "url": "https://www.hhs.gov/hipaa/for-professionals/index.html"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.522(b) — confidential communications requests; 45 CFR 164.312(e) — transmission security standard",
          "source": "45 CFR 164.522(b) — confidential communications requests; 45 CFR 164.312(e) — transmission security standard",
          "url": "https://www.ecfr.gov/current/title-45/section-164.312"
        }
      ],
      "class": "hipaa-privacy-security",
      "department": "compliance",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hip-019",
      "kind": "compliance",
      "materials": [
        "patient communication preference acknowledgment form",
        "approved message content template (appointment reminders, non-clinical logistics only)",
        "secure patient portal or encrypted messaging tool (if available)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What is the patient or staff proposing to send by text or unencrypted email?\n\nWhy: Appointment logistics carry far less risk than clinical detail or images, so the handling forks here.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "logistics-only",
              "label": "Appointment reminders or non-clinical logistics only"
            },
            {
              "goto": "s4",
              "id": "clinical-detail",
              "label": "Clinical details, treatment information, or post-op photos"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "What is the patient or staff proposing to send by text or unencrypted email?",
          "why": "Appointment logistics carry far less risk than clinical detail or images, so the handling forks here."
        },
        {
          "detail": "Use the pre-approved reminder template (date, time, general office name) with no diagnosis, treatment, or condition-specific detail.\n\nWhy: Low-content logistics messages stay within the minimum-necessary standard without needing a special risk acknowledgment.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Send using the approved non-clinical content template",
          "why": "Low-content logistics messages stay within the minimum-necessary standard without needing a special risk acknowledgment."
        },
        {
          "detail": "Non-clinical logistics message sent, no acknowledgment required",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Non-clinical logistics message sent, no acknowledgment required"
        },
        {
          "detail": "Tell the patient a secure portal or encrypted channel is available for clinical detail or photos, and offer to set it up.\n\nWhy: 45 CFR 164.312(e) favors a transmission-security-compliant channel; unencrypted SMS/email is offered only when the patient still wants it after hearing the alternative.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer the secure patient portal or encrypted messaging option first",
          "why": "45 CFR 164.312(e) favors a transmission-security-compliant channel; unencrypted SMS/email is offered only when the patient still wants it after hearing the alternative."
        },
        {
          "detail": "Does the patient still want the unencrypted channel after hearing the secure alternative?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "wants-secure",
              "label": "Patient accepts the secure portal or encrypted channel"
            },
            {
              "goto": "s7",
              "id": "wants-unencrypted",
              "label": "Patient still wants SMS or personal email"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient still want the unencrypted channel after hearing the secure alternative?"
        },
        {
          "detail": "Patient set up on the secure portal or encrypted channel instead",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient set up on the secure portal or encrypted channel instead"
        },
        {
          "detail": "Have the patient read and sign (or verbally acknowledge, documented) that texting or personal email is not encrypted, could be seen by others with access to their device or account, and that they are choosing it anyway per their right to request their preferred communication channel under 45 CFR 164.522(b).\n\nWhy: HHS guidance permits sending PHI over unencrypted channels only after an informed patient choice is documented; skipping this step is the exposure OCR audits catch.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Patient signs the unencrypted-channel risk acknowledgment.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Patient signs the unencrypted-channel risk acknowledgment",
          "why": "HHS guidance permits sending PHI over unencrypted channels only after an informed patient choice is documented; skipping this step is the exposure OCR audits catch."
        },
        {
          "detail": "Checklist before sending: (1) no diagnosis codes or billing detail; (2) no full name plus condition in the same message where avoidable; (3) images cropped/labeled to avoid unnecessary identifying background; (4) message limited to what the patient specifically asked to receive.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the message stays within the practice's approved content limits"
        },
        {
          "detail": "Send only the content cleared in the checklist, to the phone number or email address on file and confirmed with the patient.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the message via the patient's chosen unencrypted channel"
        },
        {
          "detail": "File the signed risk acknowledgment in the chart and log the date, channel and content category sent.\n\nRecord: Signed unencrypted-channel risk acknowledgment in the patient's chart, plus a log entry noting the date, channel, and general content category sent.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the signed acknowledgment and log the message sent"
        },
        {
          "detail": "Clinical message sent over the patient's acknowledged unencrypted channel",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Clinical message sent over the patient's acknowledged unencrypted channel"
        }
      ],
      "subclass": "hipaa-privacy-security-and-breach",
      "summary": "Texting and unencrypted email with patients: content limits and patient acknowledgment — A patient asks to receive clinical details by SMS or personal email, or staff propose texting post-op photos.",
      "title": "Texting and unencrypted email with patients: content limits and patient acknowledgment",
      "trigger": "A patient asks to receive clinical details by SMS or personal email, or staff propose texting post-op photos",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "label": "HIPAA Breach Notification Rule, 45 CFR 164.400-414",
          "source": "U.S. Department of Health and Human Services",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-D"
        },
        {
          "label": "HHS Breach Notification Rule guidance",
          "source": "U.S. Department of Health and Human Services, Office for Civil Rights",
          "url": "https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html"
        },
        {
          "label": "HIPAA Security Rule, 45 CFR Part 164, Subpart C",
          "source": "U.S. Department of Health and Human Services",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C"
        }
      ],
      "class": "hipaa-privacy-security",
      "id": "hipaa-phi-breach-identification-and-risk-assessment-protocol",
      "kind": "compliance",
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front_desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "steps": [
        {
          "detail": "Treat any report of lost or stolen equipment, a misdirected fax or email containing patient information, unauthorized system access, or similar as a possible breach the moment it is noticed — do not wait to confirm severity before starting this process.",
          "id": "s1",
          "kind": "step",
          "role": "front_desk",
          "title": "Recognize a possible breach"
        },
        {
          "detail": "Take the immediate step that stops further exposure: disconnect or lock the affected device, revoke the account's access, retrieve or recall the misdirected communication, or otherwise stop the information from continuing to be exposed. Do not shut down the whole system beyond what is needed to contain it — an overly broad shutdown can destroy evidence needed later.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Contain the exposure"
        },
        {
          "detail": "Leave logs, emails, devices, and system states in their current condition wherever possible. Take screenshots or photos of what is visible now rather than waiting, since screens and logs can change or roll over.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Preserve evidence"
        },
        {
          "detail": "Do not delete the misdirected email, wipe the lost device remotely before it is assessed, edit any log, or otherwise alter records connected to the incident before the privacy officer has reviewed them. Altering evidence — even with good intentions, like trying to clean up the mistake — makes the incident harder to assess accurately and is treated as a safety-critical step in this process.",
          "gate": {
            "ack": "I have not deleted, altered, or wiped anything connected to this incident, and I will not do so before the privacy officer reviews it.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "office-manager",
          "title": "Do not alter or delete anything related to the incident"
        },
        {
          "detail": "Notify the designated privacy officer immediately, by the fastest channel available (phone or in person, not just email), and give them what is known so far: what happened, when it was noticed, and what has been done to contain it.",
          "id": "s5",
          "kind": "step",
          "role": "front_desk",
          "title": "Notify the practice's privacy officer"
        },
        {
          "detail": "Open a written incident log now, and record every subsequent action with a timestamp: who was notified, what containment steps were taken, and by whom. This log becomes the practice's record of the first hour and beyond.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "incident log template"
          ],
          "role": "office-manager",
          "title": "Start the written incident log"
        },
        {
          "detail": "Work out, as specifically as the practice can at this stage, which categories of protected health information were involved — for example names, dates of birth, treatment information, insurance details, or financial information — and record this in the incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify what information was exposed"
        },
        {
          "detail": "Estimate the number of patients whose information may have been involved, even as a rough range at first. This number matters for which notification requirements apply, so refine it as more facts come in rather than guessing once and moving on.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify how many people are affected"
        },
        {
          "detail": "Determine whether the exposed information was encrypted (with the encryption key not also exposed), redacted, or otherwise rendered unusable, unreadable, or indecipherable to an unauthorized person. This materially changes the risk assessment and is a question for the privacy officer and legal counsel, not a snap judgment made in the first minutes.",
          "forks": [
            {
              "goto": "s10",
              "id": "encrypted-unusable",
              "label": "Data was encrypted/unusable to an unauthorized person"
            },
            {
              "goto": "s10",
              "id": "not-encrypted-or-unclear",
              "label": "Data was not encrypted, or this is unclear"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was the data encrypted or otherwise unusable?"
        },
        {
          "detail": "With the privacy officer, work through the standard four factors used to assess whether the exposure is a reportable breach: (1) the nature and extent of the information involved, including identifiers and likelihood of re-identification, (2) who the unauthorized person was and whether they had any obligation to protect it, (3) whether the information was actually viewed or acquired, and (4) the extent to which the risk has been mitigated. Record the answer to each factor in the incident log.",
          "id": "s10",
          "kind": "step",
          "materials": [
            "four-factor risk assessment worksheet"
          ],
          "role": "office-manager",
          "title": "Run the four-factor risk assessment"
        },
        {
          "detail": "Record the date the incident was discovered — not the date it happened — as the day the notification-timeline clock starts, and note it clearly in the incident log. This is the reference date the practice's counsel will use to determine notification deadlines; do not treat it as legal advice about what those deadlines are, since they vary with the facts.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Note the clock the notification deadlines run on"
        },
        {
          "detail": "Before deciding whether, when, or how to notify any patient, regulator, or media outlet, route the incident log and risk assessment to the practice's attorney. No external notification is sent, drafted for sending, or promised to anyone before that legal review happens. This step describes the practice's internal process and is not itself legal advice.",
          "gate": {
            "ack": "I am routing this incident to the practice's attorney and will not send, draft-for-sending, or promise any external notification before that legal review is complete.",
            "role": "attorney",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "office-manager",
          "title": "Attorney review before any external notification decision"
        },
        {
          "detail": "Bring the dentist or practice owner up to date on what is known, what has been done, and that the matter has been routed to the privacy officer and attorney for review.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief the dentist/practice owner"
        },
        {
          "detail": "Do not send any patient-facing communication, social post, or public statement about the incident until the privacy officer and attorney have reviewed the situation and approved what will be said.",
          "id": "s14",
          "kind": "step",
          "role": "front_desk",
          "title": "Hold routine communications until reviewed"
        },
        {
          "detail": "Keep adding timestamped entries to the incident log as the investigation continues past the first hour — this record is what supports the risk assessment and any later notification decision.",
          "id": "s15",
          "kind": "step",
          "materials": [
            "incident log"
          ],
          "role": "office-manager",
          "title": "Continue the incident log beyond the first hour"
        },
        {
          "detail": "Store the incident log, risk assessment, and any preserved evidence in a controlled location the privacy officer manages, separate from routine practice files, until the matter is resolved.",
          "id": "s16",
          "kind": "step",
          "role": "office-manager",
          "title": "Secure the incident record"
        }
      ],
      "summary": "What the practice does in the first hour after discovering a possible breach of protected health information: contain, preserve, identify scope, notify the privacy officer, start the incident log, run the four-factor risk assessment, and start the notification clock. Describes the practice's own process, not legal advice, and gates any external notification decision behind attorney review.",
      "title": "First Hour After a Suspected PHI Breach",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Fair Labor Standards Act exemptions, 29 CFR Part 541",
          "source": "Fair Labor Standards Act exemptions, 29 CFR Part 541",
          "url": "https://www.ecfr.gov/current/title-29/part-541"
        },
        {
          "kind": "public_domain",
          "label": "IRS worker classification guidance (Form SS-8, common-law factors)",
          "source": "IRS worker classification guidance (Form SS-8, common-law factors)",
          "url": "https://www.irs.gov/forms-pubs/about-form-ss-8"
        },
        {
          "kind": "statute",
          "label": "California Labor Code wage-and-hour provisions (DLSE)",
          "source": "California Labor Code wage-and-hour provisions (DLSE)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "annual",
      "id": "hrc-001",
      "kind": "operational",
      "materials": [
        "current job description",
        "IRS Form SS-8 worker-classification checklist",
        "FLSA duties-test checklist (executive/administrative/professional/outside sales)",
        "California salary-threshold table for exempt status"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Note whether the review is the scheduled annual review, a newly created position, or a specific offer (for example a hygienist or associate proposed as a 1099 independent contractor).\n\nWhy: Different triggers use the same test, but the record needs to show why the review happened and when.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Identify the role or engagement triggering review",
          "why": "Different triggers use the same test, but the record needs to show why the review happened and when."
        },
        {
          "detail": "Gather the job description, schedule, degree of control over hours and methods, who furnishes tools/equipment, and whether the person also works for other practices or the public.\n\nWhy: Classification tests look at real working conditions, not the job title on the offer letter.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Collect the actual working facts",
          "why": "Classification tests look at real working conditions, not the job title on the offer letter."
        },
        {
          "detail": "Score behavioral control, financial control, and relationship-type factors (benefits, permanency, integration into core clinical work) using the IRS common-law factors as the internal checklist.\n\nWhy: Misclassifying a clinician as a contractor is one of the most litigated wage-and-hour exposures in a dental practice.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Apply the employee-versus-contractor test",
          "why": "Misclassifying a clinician as a contractor is one of the most litigated wage-and-hour exposures in a dental practice."
        },
        {
          "detail": "Employee or independent contractor?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "employee",
              "label": "Classify as a W-2 employee"
            },
            {
              "goto": "s5",
              "id": "contractor",
              "label": "Classify as a 1099 independent contractor (only if every factor clearly supports it)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Employee or independent contractor?"
        },
        {
          "detail": "Test actual duties against each exemption category: executive (manages two or more FTEs, real input on hiring/firing), administrative (discretion on significant matters), professional (advanced knowledge, e.g. a licensed dentist), or none of the above (non-exempt).\n\nWhy: Exemption status depends on duties actually performed, not the job title.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "For W-2 roles, apply the exemption duties test",
          "why": "Exemption status depends on duties actually performed, not the job title."
        },
        {
          "detail": "Compare the role's salary to the current federal and state minimum salary thresholds for exempt status; use whichever threshold is higher for the practice's jurisdiction.\n\nWhy: A role can pass the duties test and still be non-exempt if paid below the applicable salary threshold.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the salary threshold",
          "why": "A role can pass the duties test and still be non-exempt if paid below the applicable salary threshold."
        },
        {
          "detail": "Exempt or non-exempt?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "nonexempt",
              "label": "Classify as non-exempt (overtime-eligible) — default when any factor is unclear"
            },
            {
              "goto": "s8",
              "id": "exempt",
              "label": "Classify as exempt (duties test and salary threshold both clearly met)"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Exempt or non-exempt?"
        },
        {
          "detail": "Practice owner reviews the completed checklist and either approves the determination or refers a borderline case to outside employment counsel or a CPA before any pay or tax-form change is made.\n\nWhy: Reclassification changes payroll tax treatment and wage-and-hour exposure; a documented sign-off protects the practice if the determination is challenged later.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner sign-off before the classification takes effect.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner sign-off before the classification takes effect",
          "why": "Reclassification changes payroll tax treatment and wage-and-hour exposure; a documented sign-off protects the practice if the determination is challenged later."
        },
        {
          "detail": "File the date, position, facts considered, test results, and sign-off name in the personnel file; retain per the applicable records-retention rule.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Document the determination"
        },
        {
          "detail": "Send the finalized classification to office-manager/payroll to update pay type, timekeeping enrollment for non-exempt roles, and any required tax-form setup.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Hand the classification to payroll"
        },
        {
          "detail": "Classification review complete",
          "id": "s11",
          "kind": "step",
          "title": "Classification review complete"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Exempt versus non-exempt and employee versus contractor classification review — A new role is created, an associate or hygienist is offered a 1099 arrangement, or the annual classification review is due.",
      "title": "Exempt versus non-exempt and employee versus contractor classification review",
      "trigger": "A new role is created, an associate or hygienist is offered a 1099 arrangement, or the annual classification review is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Fair Labor Standards Act overtime calculation, 29 CFR Part 778",
          "source": "Fair Labor Standards Act overtime calculation, 29 CFR Part 778",
          "url": "https://www.ecfr.gov/current/title-29/part-778"
        },
        {
          "kind": "statute",
          "label": "California Labor Code §226 (wage statement required items) and daily-overtime rule",
          "source": "California Labor Code §226 (wage statement required items) and daily-overtime rule",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-002",
      "kind": "operational",
      "materials": [
        "timekeeping system export",
        "meal/rest premium schedule",
        "pay period calendar",
        "wage statement template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Export clock-in/out records and any manual edits for every hourly employee for the period that is closing.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the timekeeping export for the closing pay period"
        },
        {
          "detail": "Confirm each manually edited entry carries a same-day employee acknowledgment (initialed or e-signed correction); flag any unexplained edit.\n\nWhy: Unexplained edited time is one of the first things a labor investigator asks to see.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Review every manually edited time entry",
          "why": "Unexplained edited time is one of the first things a labor investigator asks to see."
        },
        {
          "detail": "Calculate weekly overtime over 40 hours; where a state daily-overtime rule applies, also calculate daily overtime over 8 hours and double-time over 12 hours or on the 7th consecutive workday.\n\nWhy: A daily-overtime state rule is stricter than the federal weekly-only rule; applying only the federal calculation underpays employees in that state.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Calculate overtime under the applicable rule",
          "why": "A daily-overtime state rule is stricter than the federal weekly-only rule; applying only the federal calculation underpays employees in that state."
        },
        {
          "detail": "Pull the break log for the period and add one hour of premium pay per workday for each meal or rest violation type recorded.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Cross-check the meal/rest break log"
        },
        {
          "detail": "Include gross wages, total hours worked, all deductions, net wages, pay period start/end dates, employee name and identifier, employer name and address, and each hourly rate in effect with its hours.\n\nWhy: A wage statement missing a required field is a per-statement statutory violation even when the pay amount itself is correct.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the itemized wage statement",
          "why": "A wage statement missing a required field is a per-statement statutory violation even when the pay amount itself is correct."
        },
        {
          "detail": "Did an employee dispute their hours or pay before this cycle closes?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no",
              "label": "No dispute — proceed to close"
            },
            {
              "goto": "s10",
              "id": "yes",
              "label": "Yes — resolve the dispute first"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did an employee dispute their hours or pay before this cycle closes?"
        },
        {
          "detail": "Office manager confirms the overtime math, premium calculations, and wage statement fields before submitting the period to payroll processing.\n\nWhy: A second review of the calculated numbers, not just the process, catches arithmetic errors before they reach a paycheck.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor review before the pay period is finalized.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor review before the pay period is finalized",
          "why": "A second review of the calculated numbers, not just the process, catches arithmetic errors before they reach a paycheck."
        },
        {
          "detail": "Save the finalized time detail, premium calculation worksheet, and wage statement copy to payroll records for the statutory retention period.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Archive the pay period detail"
        },
        {
          "detail": "Pay period timekeeping closed",
          "id": "s9",
          "kind": "step",
          "title": "Pay period timekeeping closed"
        },
        {
          "detail": "Meet with the employee, compare their account against the time clock export, correct any confirmed error, and document the resolution in writing before the cycle closes.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Resolve the disputed entry"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Timekeeping, overtime calculation and wage statement contents — Each payroll cycle closes, or an employee disputes hours.",
      "title": "Timekeeping, overtime calculation and wage statement contents",
      "trigger": "Each payroll cycle closes, or an employee disputes hours",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §512 (meal periods) and IWC Wage Order 4 (rest periods, on-duty meal waiver conditions)",
          "source": "California Labor Code §512 (meal periods) and IWC Wage Order 4 (rest periods, on-duty meal waiver conditions)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 10,
      "frequency": "daily",
      "id": "hrc-003",
      "kind": "operational",
      "materials": [
        "daily schedule template",
        "on-duty meal waiver form",
        "break log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Block a 30-minute unpaid meal period starting before the end of the 5th hour worked for any shift over 5 hours, and a paid 10-minute rest break for each 4 hours worked or major fraction of it.\n\nWhy: The meal break must start before hour 5, not just happen sometime during the shift.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Build the day's break schedule alongside the appointment schedule",
          "why": "The meal break must start before hour 5, not just happen sometime during the shift."
        },
        {
          "detail": "Does any employee need an on-duty or waived meal period today?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no",
              "label": "No — standard off-duty meal breaks are scheduled"
            },
            {
              "goto": "s8",
              "id": "yes",
              "label": "Yes — an employee requests a waiver (only when the job truly prevents relief, e.g. sole employee on site)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does any employee need an on-duty or waived meal period today?"
        },
        {
          "detail": "Employees clock out/in for meal breaks and take rest breaks near the midpoint of each 4-hour block; the office manager watches for a break pushed past its window when a procedure runs long.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Monitor breaks through the day"
        },
        {
          "detail": "Did a scheduled break get missed, shortened, or start late?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no",
              "label": "No — breaks taken as scheduled"
            },
            {
              "goto": "s9",
              "id": "yes",
              "label": "Yes — a break was missed, short, or late"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did a scheduled break get missed, shortened, or start late?"
        },
        {
          "detail": "Log every break outcome — on time, waived, missed, premium owed — on the daily break log for the pay period.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the day's break outcomes"
        },
        {
          "detail": "Office manager reviews the week's break log and confirms every premium owed is flagged for the next payroll run before the cycle closes.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor confirms premium pay before payroll close.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor confirms premium pay before payroll close"
        },
        {
          "detail": "Day's break compliance closed out",
          "id": "s7",
          "kind": "step",
          "title": "Day's break compliance closed out"
        },
        {
          "detail": "Have the employee sign a written on-duty meal waiver naming the specific reason and stating it can be revoked in writing at any time; keep a copy in the personnel file.\n\nWhy: An on-duty meal waiver only protects the practice if it is voluntary, written, and revocable.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Document a written, voluntary on-duty meal waiver",
          "why": "An on-duty meal waiver only protects the practice if it is voluntary, written, and revocable."
        },
        {
          "detail": "Record the missed, short, or late break on the break log and add one additional hour of pay at the employee's regular rate for that workday, up to two premiums per day (one meal, one rest).\n\nWhy: Premium pay is owed per workday with a violation type, and a single day can carry both a meal premium and a rest premium.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Add the premium pay for the violation",
          "why": "Premium pay is owed per workday with a violation type, and a single day can carry both a meal premium and a rest premium."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Meal and rest break scheduling, premium pay and waiver documentation (CA addendum) — The daily schedule is built, a break is missed because a procedure ran long, or an employee requests an on-duty meal waiver.",
      "title": "Meal and rest break scheduling, premium pay and waiver documentation (CA addendum)",
      "trigger": "The daily schedule is built, a break is missed because a procedure ran long, or an employee requests an on-duty meal waiver",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Fair Labor Standards Act recordkeeping, 29 CFR Part 516",
          "source": "Fair Labor Standards Act recordkeeping, 29 CFR Part 516",
          "url": "https://www.ecfr.gov/current/title-29/part-516"
        },
        {
          "kind": "statute",
          "label": "California Labor Code payday and wage-statement requirements",
          "source": "California Labor Code payday and wage-statement requirements",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hrc-004",
      "kind": "operational",
      "materials": [
        "approved timesheets",
        "break/premium log",
        "PTO/sick leave ledger",
        "payroll processing system access"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Gather each employee's approved (electronically or manually signed) timesheet for the period; an unsigned or unapproved entry blocks close until resolved.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm all timesheets for the closing period are approved"
        },
        {
          "detail": "Compile regular hours, overtime, meal/rest premiums, and any holiday or bonus pay for each employee into the payroll worksheet.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull overtime and premium totals"
        },
        {
          "detail": "Add any approved paid time off or accrued sick leave used during the period, drawing down the current PTO/sick leave ledger balance.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Apply approved PTO and sick time"
        },
        {
          "detail": "Apply the tax withholding elections on file plus any benefit, retirement, or garnishment deductions currently in effect for each employee.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Apply standing deductions and benefit contributions"
        },
        {
          "detail": "Compare this period's gross pay per employee against the prior period and flag any variance over a set threshold for a second look before submitting.\n\nWhy: A large unexplained swing is the fastest way to catch a data-entry error before it reaches a paycheck.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Run a pre-submission accuracy check",
          "why": "A large unexplained swing is the fastest way to catch a data-entry error before it reaches a paycheck."
        },
        {
          "detail": "Practice owner (or a designated approver) reviews the payroll summary totals and approves the run before it is submitted for processing and funds move.\n\nWhy: Payroll moves real money and creates tax filings; a second-person approval before submission is the standard internal control.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner or designated approver signs off before payroll submits.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner or designated approver signs off before payroll submits",
          "why": "Payroll moves real money and creates tax filings; a second-person approval before submission is the standard internal control."
        },
        {
          "detail": "Submit the finalized, approved payroll to the payroll processing system ahead of its cutoff so pay lands on the scheduled payday.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the approved payroll run for processing"
        },
        {
          "detail": "Provide each employee their itemized wage statement at the time wages are paid, electronically or on paper, per the timekeeping-and-wage-statement protocol.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Distribute wage statements to each employee"
        },
        {
          "detail": "File the payroll register, the owner sign-off, and copies of wage statements in payroll records for the statutory retention period.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Archive the payroll register and approvals"
        },
        {
          "detail": "Payroll cycle closed",
          "id": "s10",
          "kind": "step",
          "title": "Payroll cycle closed"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Payroll cycle processing (timesheets, breaks, overtime, PTO, approvals) — Each pay period ends.",
      "title": "Payroll cycle processing (timesheets, breaks, overtime, PTO, approvals)",
      "trigger": "Each pay period ends",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §246 — paid sick leave accrual and use",
          "source": "California Labor Code §246 — paid sick leave accrual and use",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hrc-005",
      "kind": "operational",
      "materials": [
        "PTO/sick leave ledger",
        "time-off request form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Log the employee's requested dates, whether it is discretionary PTO or protected paid sick leave, and the date the request was made.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the time-off request"
        },
        {
          "detail": "Look up current PTO and paid-sick-leave balances against the requested hours; California guarantees at least 24 hours or 3 days of paid sick leave per year regardless of the accrual method used.\n\nWhy: Paid sick leave carries its own statutory floor, separate from any discretionary PTO the practice offers.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the employee's accrued balance",
          "why": "Paid sick leave carries its own statutory floor, separate from any discretionary PTO the practice offers."
        },
        {
          "detail": "Is this discretionary PTO or protected paid sick leave?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "sick",
              "label": "Paid sick leave (illness, preventive care, or safe-time use)"
            },
            {
              "goto": "s8",
              "id": "pto",
              "label": "Discretionary PTO / vacation"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this discretionary PTO or protected paid sick leave?"
        },
        {
          "detail": "Approve the request; California does not allow requiring advance notice or a doctor's note to use accrued sick time for a routine short absence.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Approve protected sick leave without an advance-notice or note requirement"
        },
        {
          "detail": "Arrange coverage on the appointment schedule for the approved absence and confirm the remaining team is informed.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Adjust the schedule for the approved dates"
        },
        {
          "detail": "Deduct the approved hours from the balance, note the approval date and approver, and block the dates on the scheduling calendar.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Post the approved leave to the ledger and calendar"
        },
        {
          "detail": "Time-off request resolved",
          "id": "s7",
          "kind": "step",
          "title": "Time-off request resolved"
        },
        {
          "detail": "Confirm the requested dates do not leave the schedule without required coverage; if they do, discuss alternate dates with the employee rather than an outright denial where feasible.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Check schedule coverage before approving discretionary PTO"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "PTO and paid sick leave requests — An employee requests time off.",
      "title": "PTO and paid sick leave requests",
      "trigger": "An employee requests time off",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Family and Medical Leave Act, 29 CFR Part 825",
          "source": "Family and Medical Leave Act, 29 CFR Part 825",
          "url": "https://www.ecfr.gov/current/title-29/part-825"
        },
        {
          "kind": "statute",
          "label": "California Family Rights Act (Gov. Code §12945.2) and pregnancy disability leave",
          "source": "California Family Rights Act (Gov. Code §12945.2) and pregnancy disability leave",
          "url": "https://calcivilrights.ca.gov/shpt/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-006",
      "kind": "operational",
      "materials": [
        "FMLA/CFRA notice and certification forms",
        "pregnancy disability leave notice",
        "leave tracking log kept separate from personnel files"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager",
        "scheduler",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note whether the employee cites their own or a family member's serious health condition, pregnancy or childbirth, bonding with a new child, jury duty, or military service.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Receive the leave request and identify the likely leave type"
        },
        {
          "detail": "Confirm employer size and employee tenure/hours thresholds for federal family leave and any state family-rights leave; state pregnancy disability leave commonly has no employer-size minimum and no tenure requirement.\n\nWhy: State family-rights and pregnancy-disability leave laws often cover far more small practices than the federal leave law because their thresholds are lower.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Check statutory eligibility",
          "why": "State family-rights and pregnancy-disability leave laws often cover far more small practices than the federal leave law because their thresholds are lower."
        },
        {
          "detail": "Provide the employee written notice of their eligibility, rights, and responsibilities within the required window, using the applicable federal and state leave notice.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Send the required eligibility and rights notice"
        },
        {
          "detail": "Does this leave type require medical certification?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "yes",
              "label": "Yes — request certification (own/family serious health condition, pregnancy disability)"
            },
            {
              "goto": "s6",
              "id": "no",
              "label": "No certification required (bonding, jury duty, military)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "hr",
          "title": "Does this leave type require medical certification?"
        },
        {
          "detail": "Send the certification form to the employee with the statutory return deadline (commonly 15 calendar days); follow up once on an incomplete form rather than denying the leave outright.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Request and track medical certification"
        },
        {
          "detail": "HR or the compliance officer reviews the eligibility determination and any denial or limitation before it goes to the employee.\n\nWhy: Protected-leave denials, and even well-intentioned scheduling pressure during leave, are a frequent source of retaliation claims; a second review before the decision is communicated reduces that risk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: HR/compliance confirms the leave decision before it is communicated.",
            "role": "hr",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "hr",
          "title": "HR/compliance confirms the leave decision before it is communicated",
          "why": "Protected-leave denials, and even well-intentioned scheduling pressure during leave, are a frequent source of retaliation claims; a second review before the decision is communicated reduces that risk."
        },
        {
          "detail": "Provide scheduling with the approved start date, expected duration, and any intermittent-leave pattern so coverage can be arranged.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Hand the approved leave dates to scheduling"
        },
        {
          "detail": "Confirm health benefit continuation during the leave and document the job, or an equivalent job, the employee is guaranteed on return.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Confirm benefits continuation and job-restoration rights"
        },
        {
          "detail": "File the request, notice, certification, approval, and return-to-work confirmation in a leave file kept separate from the general personnel file.\n\nWhy: Medical certification content is sensitive and should be stored apart from the general personnel file.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Document the leave file",
          "why": "Medical certification content is sensitive and should be stored apart from the general personnel file."
        },
        {
          "detail": "Protected leave request resolved",
          "id": "s10",
          "kind": "step",
          "title": "Protected leave request resolved"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Protected leave request handling (FMLA/CFRA, pregnancy disability, bonding, jury, military) — An employee asks for extended leave for their own or a family member’s serious health condition, pregnancy, bonding or military service.",
      "title": "Protected leave request handling (FMLA/CFRA, pregnancy disability, bonding, jury, military)",
      "trigger": "An employee asks for extended leave for their own or a family member’s serious health condition, pregnancy, bonding or military service",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Americans with Disabilities Act Title I / EEOC reasonable accommodation guidance",
          "source": "Americans with Disabilities Act Title I / EEOC reasonable accommodation guidance",
          "url": "https://www.eeoc.gov/laws/guidance/enforcement-guidance-reasonable-accommodation-and-undue-hardship-under-ada"
        },
        {
          "kind": "statute",
          "label": "California Fair Employment and Housing Act (Gov. Code §12940 et seq.)",
          "source": "California Fair Employment and Housing Act (Gov. Code §12940 et seq.)",
          "url": "https://calcivilrights.ca.gov/shpt/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-007",
      "kind": "operational",
      "materials": [
        "interactive process worksheet",
        "essential job functions list",
        "accommodation request form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note the request in the employee's own words — a modified schedule, equipment, duty change, or disclosed pregnancy — even if they do not use the words 'reasonable accommodation.'\n\nWhy: An employee never has to use specific legal language to trigger the duty to engage in the interactive process.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Receive the accommodation request",
          "why": "An employee never has to use specific legal language to trigger the duty to engage in the interactive process."
        },
        {
          "detail": "Pull the current job description and confirm which listed duties are truly essential versus marginal for that position.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Identify the essential functions of the role"
        },
        {
          "detail": "Meet with the employee to discuss the limitation, the essential functions, and possible accommodation options; invite the employee to suggest options they believe would work.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Hold the interactive process meeting"
        },
        {
          "detail": "Is supporting medical documentation needed to identify an accommodation?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no",
              "label": "No — the limitation and needed accommodation are already clear"
            },
            {
              "goto": "s10",
              "id": "yes",
              "label": "Yes — request limited medical documentation"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "hr",
          "title": "Is supporting medical documentation needed to identify an accommodation?"
        },
        {
          "detail": "List options such as a schedule adjustment, modified duties, equipment, a temporary transfer, or unpaid leave as a last resort, and assess each against undue hardship for the practice.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Identify possible accommodations"
        },
        {
          "detail": "Practice owner reviews and approves the accommodation HR recommends, or the denial and its stated undue-hardship basis, before it is communicated to the employee.\n\nWhy: The final call and its documented business reason should sit with the person who can attest to operational impact if the decision is later challenged.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner sign-off on the selected accommodation.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner sign-off on the selected accommodation",
          "why": "The final call and its documented business reason should sit with the person who can attest to operational impact if the decision is later challenged."
        },
        {
          "detail": "Put the approved schedule, equipment, or duty change into effect on the agreed start date and confirm with the employee that it is working as intended.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Implement the approved accommodation"
        },
        {
          "detail": "File the request, meeting notes, any medical documentation received (kept separate from the personnel file), options considered, and the final decision with its basis.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Document the interactive process"
        },
        {
          "detail": "Interactive process closed",
          "id": "s9",
          "kind": "step",
          "title": "Interactive process closed"
        },
        {
          "detail": "Request documentation limited to the nature of the limitation and the needed restrictions — not a full diagnosis or unrelated medical history.\n\nWhy: Requesting more medical detail than necessary to evaluate the accommodation is itself a compliance risk.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Request only the medical information needed",
          "why": "Requesting more medical detail than necessary to evaluate the accommodation is itself a compliance risk."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Disability or religious accommodation interactive process — An employee requests a modified schedule, equipment or duty change for a medical or religious reason, including a disclosed pregnancy.",
      "title": "Disability or religious accommodation interactive process",
      "trigger": "An employee requests a modified schedule, equipment or duty change for a medical or religious reason, including a disclosed pregnancy",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California SB 1343 harassment prevention training requirement (Gov. Code §12950.1)",
          "source": "California SB 1343 harassment prevention training requirement (Gov. Code §12950.1)",
          "url": "https://calcivilrights.ca.gov/shpt/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hrc-008",
      "kind": "operational",
      "materials": [
        "interactive harassment-prevention training course (supervisory and non-supervisory tracks)",
        "training completion tracking log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "all-staff",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Run the staff roster against hire dates and last completion dates: new hires are due within six months of hire, all staff are due again every two years, and anyone promoted into a supervisory role is due before or within six months of the promotion.\n\nWhy: The first-year deadline for new hires is shorter than the recurring two-year cycle, so a roster check by hire date catches people a simple calendar reminder would miss.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Identify who is due for training",
          "why": "The first-year deadline for new hires is shorter than the recurring two-year cycle, so a roster check by hire date catches people a simple calendar reminder would miss."
        },
        {
          "detail": "Is the employee supervisory or non-supervisory for training purposes?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "non",
              "label": "Non-supervisory — 1 hour of training required"
            },
            {
              "goto": "s3",
              "id": "sup",
              "label": "Supervisory — 2 hours of training required"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hr",
          "title": "Is the employee supervisory or non-supervisory for training purposes?"
        },
        {
          "detail": "Enroll the employee in a course covering federal and state harassment, discrimination, and retaliation law plus abusive-conduct examples relevant to a small workplace; the training must be interactive, not a passive video with no engagement.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Enroll in an interactive course covering the required content"
        },
        {
          "detail": "Employee completes the full required hours before their individual deadline; supervisors additionally cover how to respond to a harassment complaint.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Complete the training within the deadline"
        },
        {
          "detail": "Record the completion date, hours, and course content summary in the training tracking log so the record can demonstrate compliance if ever requested.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Log completion"
        },
        {
          "detail": "HR reviews the tracking log each cycle and flags anyone who has passed their individual deadline for immediate follow-up.\n\nWhy: The training requirement is a hard statutory deadline per employee, not a batch event, so a single missed date is a real exposure even if most of the staff is current.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance check for anyone past deadline.",
            "role": "hr",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "hr",
          "title": "Compliance check for anyone past deadline",
          "why": "The training requirement is a hard statutory deadline per employee, not a batch event, so a single missed date is a real exposure even if most of the staff is current."
        },
        {
          "detail": "Is anyone past their training deadline?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no",
              "label": "No — all current"
            },
            {
              "goto": "s10",
              "id": "yes",
              "label": "Yes — escalate for immediate scheduling"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "hr",
          "title": "Is anyone past their training deadline?"
        },
        {
          "detail": "Update next-due dates for everyone completed this cycle and confirm the master calendar reflects the new two-year deadlines.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Update the master training calendar"
        },
        {
          "detail": "Training cycle updated",
          "id": "s9",
          "kind": "step",
          "title": "Training cycle updated"
        },
        {
          "detail": "Hand the overdue names to office-manager to schedule the make-up session within the week and note the delay and reason in the log.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate overdue training for immediate scheduling"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Sexual harassment prevention training (CA: within six months of hire, every two years; longer for supervisors) — A new hire reaches month five, a supervisor is promoted, or the two-year cycle date arrives.",
      "title": "Sexual harassment prevention training (CA: within six months of hire, every two years; longer for supervisors)",
      "trigger": "A new hire reaches month five, a supervisor is promoted, or the two-year cycle date arrives",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Title VII / EEOC harassment guidance; California FEHA (Gov. Code §12940 et seq.)",
          "source": "Title VII / EEOC harassment guidance; California FEHA (Gov. Code §12940 et seq.)",
          "url": "https://calcivilrights.ca.gov/shpt/"
        },
        {
          "kind": "regulation",
          "label": "EEOC Enforcement Guidance on Harassment in the Workplace",
          "source": "EEOC Enforcement Guidance on Harassment in the Workplace",
          "url": "https://www.eeoc.gov/laws/guidance/enforcement-guidance-harassment-workplace"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "hrc-009",
      "kind": "operational",
      "materials": [
        "Written complaint intake form",
        "Interview question outline",
        "Confidential investigation log",
        "Anti-retaliation notice text",
        "Findings and remedial-action memo template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Take the employee to a private room, thank them for coming forward, and let them describe what happened without interruption.\n\nWhy: A calm, private, non-judgmental intake reduces the chance the employee stops talking or feels punished for reporting.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Receive the report calmly and in private",
          "why": "A calm, private, non-judgmental intake reduces the chance the employee stops talking or feels punished for reporting."
        },
        {
          "detail": "Is there an immediate safety risk to the reporting employee?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-risk",
              "label": "No immediate safety risk"
            },
            {
              "goto": "s15",
              "id": "risk",
              "label": "Immediate risk — separate the parties now"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is there an immediate safety risk to the reporting employee?"
        },
        {
          "detail": "Write down who, what, when, where, witnesses named, and the employee's own words, then have the employee review it for accuracy.\n\nWhy: A contemporaneous written record protects both the employee and the practice if the matter is later disputed or escalates to an agency.\n\nRecord: Written complaint intake form, dated and signed by the reporting employee where possible",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Document the initial report in writing",
          "why": "A contemporaneous written record protects both the employee and the practice if the matter is later disputed or escalates to an agency."
        },
        {
          "detail": "Tell the employee directly that retaliation for reporting in good faith is prohibited, and give them a name to contact if they experience any change in treatment.\n\nWhy: Retaliation is a separate, independently actionable claim under FEHA and Title VII even if the underlying harassment charge is not substantiated.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "State the anti-retaliation protection explicitly",
          "why": "Retaliation is a separate, independently actionable claim under FEHA and Title VII even if the underlying harassment charge is not substantiated."
        },
        {
          "detail": "Confirm the person conducting the investigation is not the accused, does not report to the accused, and is not a close personal relation of either party; use an outside investigator if every internal option is conflicted.\n\nWhy: An investigator with a conflict of interest — real or perceived — undermines the credibility of the findings and can itself become a retaliation claim.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Assign an investigator with no conflict of interest.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Assign an investigator with no conflict of interest",
          "why": "An investigator with a conflict of interest — real or perceived — undermines the credibility of the findings and can itself become a retaliation claim."
        },
        {
          "detail": "Use the interview outline to get specific incidents, dates, witnesses and any documentation (texts, emails, photos) the employee already has.\n\nWhy: Specific, dated incidents are far more defensible in an investigation than a general characterization.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Interview the reporting employee in detail",
          "why": "Specific, dated incidents are far more defensible in an investigation than a general characterization."
        },
        {
          "detail": "Present the allegations factually, let the accused respond fully, and take notes without arguing the merits during the interview.\n\nWhy: Due process for the accused is part of a defensible investigation and reduces wrongful-termination exposure if discipline follows.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Interview the accused employee",
          "why": "Due process for the accused is part of a defensible investigation and reduces wrongful-termination exposure if discipline follows."
        },
        {
          "detail": "Interview each witness named by either party separately, asking open questions rather than leading ones.\n\nWhy: Independent witness accounts are what turns a he-said/she-said into a substantiated or unsubstantiated finding.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Interview named witnesses",
          "why": "Independent witness accounts are what turns a he-said/she-said into a substantiated or unsubstantiated finding."
        },
        {
          "detail": "Is the complaint substantiated on a preponderance of the evidence?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "substantiated",
              "label": "Substantiated — proceed to corrective action"
            },
            {
              "goto": "s16",
              "id": "unsubstantiated",
              "label": "Unsubstantiated — close with findings memo"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is the complaint substantiated on a preponderance of the evidence?"
        },
        {
          "detail": "Route the substantiated findings and recommended discipline (per the progressive-discipline protocol) to the practice owner for a decision and, where warranted, licensing-board or law-enforcement referral.\n\nWhy: Discipline decisions carry legal and employment consequences that belong with the person accountable for the practice.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Hand findings to the practice owner for corrective action",
          "why": "Discipline decisions carry legal and employment consequences that belong with the person accountable for the practice."
        },
        {
          "detail": "File the intake form, interview notes, findings memo and discipline outcome in the confidential investigation log, kept separate from the general personnel file.\n\nWhy: Keeping investigation files separate from routine personnel files limits access to those with a genuine need to know.\n\nRecord: Confidential investigation log",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "File the complete investigation file",
          "why": "Keeping investigation files separate from routine personnel files limits access to those with a genuine need to know."
        },
        {
          "detail": "Set a reminder to check in privately with the reporting employee 30 days after case closure to confirm no retaliation has occurred.\n\nWhy: Retaliation often surfaces weeks after a case closes, once attention has moved elsewhere.",
          "id": "s12",
          "kind": "timer",
          "role": "hr",
          "timer_seconds": 2592000,
          "title": "Check in at 30 days to confirm no retaliation",
          "why": "Retaliation often surfaces weeks after a case closes, once attention has moved elsewhere."
        },
        {
          "detail": "Set a second reminder to check in privately with the reporting employee 90 days after case closure to confirm no retaliation has occurred.\n\nWhy: A second, later checkpoint catches retaliation that surfaces after the first check-in.",
          "id": "s13",
          "kind": "timer",
          "role": "hr",
          "timer_seconds": 5184000,
          "title": "Check in again at 90 days to confirm no retaliation",
          "why": "A second, later checkpoint catches retaliation that surfaces after the first check-in."
        },
        {
          "detail": "Investigation closed",
          "id": "s14",
          "kind": "step",
          "role": "hr",
          "title": "Investigation closed"
        },
        {
          "detail": "Temporarily adjust the schedule, physical location, or reporting line so the accused and the reporting employee do not have to work the same shift while the investigation proceeds.\n\nWhy: Interim separation protects the reporting employee without pre-judging the outcome.",
          "id": "s15",
          "kind": "step",
          "role": "office-manager",
          "title": "Put interim measures in place",
          "why": "Interim separation protects the reporting employee without pre-judging the outcome."
        },
        {
          "detail": "Document what was investigated, what evidence was reviewed, and why the evidence did not support the allegation; do not label the reporting employee as untruthful.\n\nWhy: Unsubstantiated does not mean untrue — the record should stay neutral so the reporting employee is not chilled from reporting again.\n\nRecord: Confidential investigation log, findings memo",
          "id": "s16",
          "kind": "step",
          "role": "hr",
          "title": "Write and file the unsubstantiated-findings memo",
          "why": "Unsubstantiated does not mean untrue — the record should stay neutral so the reporting employee is not chilled from reporting again."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Harassment, discrimination or retaliation complaint intake and investigation — An employee reports harassment by a coworker, supervisor, dentist or patient.",
      "title": "Harassment, discrimination or retaliation complaint intake and investigation",
      "trigger": "An employee reports harassment by a coworker, supervisor, dentist or patient",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §5401 (workers' compensation claim form within one working day of knowledge of injury)",
          "source": "California Labor Code §5401 (workers' compensation claim form within one working day of knowledge of injury)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA injury and illness recordkeeping requirements",
          "source": "Cal/OSHA injury and illness recordkeeping requirements",
          "url": "https://www.dir.ca.gov/dosh/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "hrc-010",
      "kind": "operational",
      "materials": [
        "First-aid kit",
        "DWC-1 workers' compensation claim form",
        "Panel of pre-designated treating physicians",
        "Incident report template",
        "Return-to-work / modified-duty form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "all-staff",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Before administering first aid, quickly check for severe bleeding, chest pain, difficulty breathing, loss of consciousness, or a major burn.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "red-flag",
              "label": "Yes — a red-flag sign is present"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "no-red-flag",
              "label": "No red-flag signs — proceed with first aid"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "all-staff",
          "title": "Rapid check: any life-threatening signs?"
        },
        {
          "detail": "For a serious injury, call 911; for a moderate injury that does not need EMS, transport or send the employee to urgent care or the designated treating physician.\n\nWhy: The employee's health comes before any paperwork step.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Call 911 or transport to urgent care immediately",
          "why": "The employee's health comes before any paperwork step."
        },
        {
          "detail": "Tell the office manager what happened, when, and the employee's current condition as soon as care is underway.\n\nWhy: The one-working-day claim-form clock under Labor Code §5401 starts from when the employer knows of the injury, so prompt notice matters.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Notify the office manager or practice owner",
          "why": "The one-working-day claim-form clock under Labor Code §5401 starts from when the employer knows of the injury, so prompt notice matters."
        },
        {
          "detail": "Give the injured employee the claim form and a copy of the workers' compensation pamphlet no later than one working day after learning of the injury; complete the employer portion and forward to the carrier.\n\nWhy: California Labor Code §5401 sets a one-working-day deadline for providing the claim form once the employer knows of the injury.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Provide the DWC-1 workers' compensation claim form within one working day",
          "why": "California Labor Code §5401 sets a one-working-day deadline for providing the claim form once the employer knows of the injury."
        },
        {
          "detail": "Record what happened, where, when, contributing factors (wet floor, awkward lift, equipment malfunction), and any witnesses.\n\nWhy: A factual incident report supports the workers' compensation claim and feeds the practice's injury-prevention review.\n\nRecord: Incident report template; entered on the Cal/OSHA injury and illness log if recordable",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete the incident report",
          "why": "A factual incident report supports the workers' compensation claim and feeds the practice's injury-prevention review."
        },
        {
          "detail": "Does this meet Cal/OSHA recordability criteria (lost time, medical treatment beyond first aid, restricted duty)?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "not-recordable",
              "label": "First aid only, not recordable"
            },
            {
              "goto": "s13",
              "id": "recordable",
              "label": "Recordable — log it"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does this meet Cal/OSHA recordability criteria (lost time, medical treatment beyond first aid, restricted duty)?"
        },
        {
          "detail": "Collect work-status notes from the treating physician after each visit and keep them with the claim file, not the general personnel file.\n\nWhy: Medical work-status notes are PHI and belong in a claim file with restricted access, separate from the ordinary personnel file.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Track follow-up care and work-status notes",
          "why": "Medical work-status notes are PHI and belong in a claim file with restricted access, separate from the ordinary personnel file."
        },
        {
          "detail": "Did the treating physician release the employee to modified duty?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "modified-duty",
              "label": "Released to modified duty — build a temporary task list"
            },
            {
              "goto": "s10",
              "id": "full-duty",
              "label": "Released to full duty"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the treating physician release the employee to modified duty?"
        },
        {
          "detail": "Match the physician's restrictions to tasks the employee can safely perform (e.g., no lifting over 10 lbs, seated work) until the next status note.\n\nWhy: A documented modified-duty offer supports the employee's recovery and is often required to keep the claim active and cost-controlled.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Build a temporary modified-duty task list",
          "why": "A documented modified-duty offer supports the employee's recovery and is often required to keep the claim active and cost-controlled."
        },
        {
          "detail": "Injury handled and documented",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Injury handled and documented"
        },
        {
          "detail": "Stop what is happening, apply first aid (clean and dress a cut, cool a burn, rest a strain) using the office first-aid kit.\n\nWhy: Prompt first aid limits the severity of a minor injury and shows the practice acted immediately, which matters for the claim record.",
          "id": "s11",
          "kind": "step",
          "role": "all-staff",
          "title": "Provide immediate first aid",
          "why": "Prompt first aid limits the severity of a minor injury and shows the practice acted immediately, which matters for the claim record."
        },
        {
          "detail": "Does the injury need emergency care beyond first aid?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "first-aid-only",
              "label": "First aid is sufficient"
            },
            {
              "goto": "s2",
              "id": "needs-er",
              "label": "Needs urgent or emergency medical care — call 911 or transport to urgent care"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the injury need emergency care beyond first aid?"
        },
        {
          "detail": "Add the case to the log within the required timeframe, including days away from work or on restricted duty.\n\nWhy: Accurate recordkeeping is required and is what a Cal/OSHA inspection will check first.\n\nRecord: Cal/OSHA injury and illness log",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Enter the injury on the Cal/OSHA injury and illness log",
          "why": "Accurate recordkeeping is required and is what a Cal/OSHA inspection will check first."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Employee injury or occupational illness — first aid, claim form within one working day, employer report and return-to-work — A team member is hurt at work (slip, lifting strain, sterilizer burn) or reports an occupational illness.",
      "title": "Employee injury or occupational illness — first aid, claim form within one working day, employer report and return-to-work",
      "trigger": "A team member is hurt at work (slip, lifting strain, sterilizer burn) or reports an occupational illness",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §1198.5 (personnel file inspection right, 30-day response window)",
          "source": "California Labor Code §1198.5 (personnel file inspection right, 30-day response window)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-011",
      "kind": "operational",
      "materials": [
        "Personnel file checklist",
        "File request log",
        "Redaction template for third-party names",
        "Locked file cabinet or access-controlled digital folder"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Is this a new document to file or an inspection request?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-document",
              "label": "New document to add to a file"
            },
            {
              "goto": "s5",
              "id": "inspection-request",
              "label": "Employee or former employee inspection request"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "hr",
          "title": "Is this a new document to file or an inspection request?"
        },
        {
          "detail": "Sort the document into personnel file, medical/claim file, or investigation file per the checklist — never mix medical or investigation records into the general personnel file.\n\nWhy: California and federal rules require medical information and investigation records to be kept separate from the general personnel file with restricted access.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Classify the document before filing",
          "why": "California and federal rules require medical information and investigation records to be kept separate from the general personnel file with restricted access."
        },
        {
          "detail": "Place the document in the appropriate file, in chronological order, and update the file checklist to reflect what was added.\n\nWhy: A complete, organized file is what makes a 30-day response to an inspection request achievable.\n\nRecord: Personnel file checklist",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "File the document in the correct location",
          "why": "A complete, organized file is what makes a 30-day response to an inspection request achievable."
        },
        {
          "detail": "Personnel file request or filing complete",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Personnel file request or filing complete"
        },
        {
          "detail": "Record the requester's name, employment status (current or former), what they are requesting, and the date received.\n\nWhy: The 30-day clock under Labor Code §1198.5 starts on the date the request is received, so the date must be captured precisely.\n\nRecord: File request log",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Log the inspection or copy request with the date received",
          "why": "The 30-day clock under Labor Code §1198.5 starts on the date the request is received, so the date must be captured precisely."
        },
        {
          "detail": "Pull every document that must be disclosed under the personnel-file-inspection right, excluding records the statute allows to be withheld (e.g., letters of reference, records of a criminal investigation).\n\nWhy: Withholding documents that should be disclosed, or disclosing ones that should be withheld, both create legal exposure.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Gather the complete personnel file",
          "why": "Withholding documents that should be disclosed, or disclosing ones that should be withheld, both create legal exposure."
        },
        {
          "detail": "Does the file contain another employee's personal information (e.g., a witness named in an investigation)?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-third-party",
              "label": "No third-party personal information present"
            },
            {
              "goto": "s10",
              "id": "third-party-present",
              "label": "Redact third-party names before disclosure"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "hr",
          "title": "Does the file contain another employee's personal information (e.g., a witness named in an investigation)?"
        },
        {
          "detail": "Make the file available for inspection at the workplace, or mail a copy, within 30 calendar days of the request.\n\nWhy: Labor Code §1198.5 sets a 30-day statutory deadline; missing it is itself a violation regardless of the file's contents.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Provide the file for inspection or a copy within 30 days",
          "why": "Labor Code §1198.5 sets a 30-day statutory deadline; missing it is itself a violation regardless of the file's contents."
        },
        {
          "detail": "Record the date the file was provided and confirm it fell within the 30-day window.\n\nWhy: Closing the log entry creates the audit trail that shows the deadline was met.\n\nRecord: File request log",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Close out the request log entry",
          "why": "Closing the log entry creates the audit trail that shows the deadline was met."
        },
        {
          "detail": "Use the redaction template to remove or black out any other employee's name or identifying detail before providing the copy.\n\nWhy: The inspecting employee has a right to their own file, not to another employee's private information contained within it.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Redact other employees' personal information",
          "why": "The inspecting employee has a right to their own file, not to another employee's private information contained within it."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Personnel file maintenance and employee inspection request (CA: 30 days) — A current or former employee requests their file, or a document is added.",
      "title": "Personnel file maintenance and employee inspection request (CA: 30 days)",
      "trigger": "A current or former employee requests their file, or a document is added",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California at-will employment framework and public-policy limits on termination (Labor Code §2922; Tameny v. Atlantic Richfield public-policy exception)",
          "source": "California at-will employment framework and public-policy limits on termination (Labor Code §2922; Tameny v. Atlantic Richfield public-policy exception)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-012",
      "kind": "operational",
      "materials": [
        "Progressive discipline policy",
        "Written warning template",
        "Prior discipline history for the employee",
        "Employee handbook acknowledgment"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Write down the specific behavior or policy violation, with dates, rather than a general impression (e.g., 'arrived 20 minutes late on three of the last five shifts' rather than 'bad attitude').\n\nWhy: Specific, factual documentation is what makes discipline defensible if it is later challenged.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the specific, factual issue",
          "why": "Specific, factual documentation is what makes discipline defensible if it is later challenged."
        },
        {
          "detail": "Check whether this is a first occurrence, a repeat of a prior verbal or written warning, or an escalation.\n\nWhy: Progressive discipline only works, and only protects the practice, if each step reflects genuine escalation rather than skipping steps inconsistently between employees.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the employee's prior discipline history",
          "why": "Progressive discipline only works, and only protects the practice, if each step reflects genuine escalation rather than skipping steps inconsistently between employees."
        },
        {
          "detail": "How severe is this occurrence?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "minor-first",
              "label": "Minor, first occurrence — verbal coaching"
            },
            {
              "goto": "s6",
              "id": "repeat-or-serious",
              "label": "Repeat occurrence or serious violation — written warning"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "How severe is this occurrence?"
        },
        {
          "detail": "Have a private conversation describing the issue and the expected standard; make a brief dated note for your own records even though this step is not a formal written warning.\n\nWhy: Early, low-formality coaching resolves many issues without escalation and shows good faith if a pattern later develops.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Deliver verbal coaching and note it informally",
          "why": "Early, low-formality coaching resolves many issues without escalation and shows good faith if a pattern later develops."
        },
        {
          "detail": "Discipline step documented",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Discipline step documented"
        },
        {
          "detail": "Draft the written warning using the template: the specific issue, prior related discipline, the expected standard, and the consequence of recurrence.\n\nWhy: Preparing the document before the conversation keeps the discussion focused and consistent with what gets signed.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare the written warning before the conversation",
          "why": "Preparing the document before the conversation keeps the discussion focused and consistent with what gets signed."
        },
        {
          "detail": "If this written warning is the last step before possible termination, have the practice owner review the document and confirm consistency with how similar issues were handled for other employees.\n\nWhy: Inconsistent discipline across employees is a common basis for discrimination claims; a second set of eyes catches that before delivery.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Have the practice owner review before delivery when termination could follow.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Have the practice owner review before delivery when termination could follow",
          "why": "Inconsistent discipline across employees is a common basis for discrimination claims; a second set of eyes catches that before delivery."
        },
        {
          "detail": "Meet privately, state the issue factually, let the employee respond, and explain the expected standard and timeline for improvement.\n\nWhy: A private, respectful conversation reduces the chance of a separate claim of humiliation or public embarrassment.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Deliver the warning in a private conversation",
          "why": "A private, respectful conversation reduces the chance of a separate claim of humiliation or public embarrassment."
        },
        {
          "detail": "Will the employee sign the warning?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "signs",
              "label": "Employee signs"
            },
            {
              "goto": "s12",
              "id": "refuses",
              "label": "Employee refuses to sign"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Will the employee sign the warning?"
        },
        {
          "detail": "Place the completed, signed (or witnessed) warning in the employee's personnel file and update the discipline history log.\n\nWhy: The written record is what makes the next step of progressive discipline, if needed, defensible.\n\nRecord: Personnel file, discipline history log",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "File the signed warning in the personnel file",
          "why": "The written record is what makes the next step of progressive discipline, if needed, defensible."
        },
        {
          "detail": "Set a reminder for the date named in the warning to check whether the behavior improved.\n\nWhy: A follow-up check is what shows the warning was a genuine improvement opportunity, not a pretext for termination.",
          "id": "s11",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1209600,
          "title": "Schedule a follow-up check within the stated improvement window",
          "why": "A follow-up check is what shows the warning was a genuine improvement opportunity, not a pretext for termination."
        },
        {
          "detail": "Write 'employee declined to sign' on the form with the date, and have a second manager or witness sign confirming the warning was delivered and read.\n\nWhy: A refusal to sign does not undo the warning, but the record must show it was delivered regardless.\n\nRecord: Written warning template, refusal noted",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Note the refusal and have a witness sign",
          "why": "A refusal to sign does not undo the warning, but the record must show it was delivered regardless."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Progressive discipline, corrective-action conversation and documentation — Repeated tardiness, a policy violation or a performance issue needs a written warning.",
      "title": "Progressive discipline, corrective-action conversation and documentation",
      "trigger": "Repeated tardiness, a policy violation or a performance issue needs a written warning",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Federal poster requirements (FLSA, EEOC, FMLA) and Cal/OSHA / California Labor Commissioner required workplace postings",
          "source": "Federal poster requirements (FLSA, EEOC, FMLA) and Cal/OSHA / California Labor Commissioner required workplace postings",
          "url": "https://www.dir.ca.gov/wpnodb.asp"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "annual",
      "id": "hrc-013",
      "kind": "operational",
      "materials": [
        "Current federal poster set (FLSA, EEOC, FMLA, OSHA)",
        "Current California poster set (minimum wage, paid sick leave, workers' comp, harassment)",
        "Poster placement checklist",
        "Break room / employee-visible posting area"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm this is the January annual check, or that a specific law change (minimum wage, a new leave requirement) has been flagged.\n\nWhy: Poster content changes most often at the calendar-year boundary and whenever the minimum wage or a leave law changes mid-year.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the audit trigger",
          "why": "Poster content changes most often at the calendar-year boundary and whenever the minimum wage or a leave law changes mid-year."
        },
        {
          "detail": "Confirm the checklist covers: federal minimum wage/FLSA, EEOC 'Know Your Rights', FMLA, OSHA 'Job Safety and Health', California minimum wage, paid sick leave, workers' compensation notice, and sexual harassment prevention notice.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current required poster checklist"
        },
        {
          "detail": "Walk to the employee-visible posting area and check each poster's effective date or version against the current checklist.\n\nWhy: An outdated minimum-wage or leave poster is a common, easily avoided compliance gap that shows up first in any labor audit.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Physically inspect the current posted set",
          "why": "An outdated minimum-wage or leave poster is a common, easily avoided compliance gap that shows up first in any labor audit."
        },
        {
          "detail": "Are any posters missing or outdated?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "current",
              "label": "All posters current and complete"
            },
            {
              "goto": "s7",
              "id": "gaps-found",
              "label": "Gaps found — order and replace"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are any posters missing or outdated?"
        },
        {
          "detail": "Record the date of the audit, what was checked, and what (if anything) was replaced.\n\nWhy: A dated audit log is what demonstrates due diligence if the posting is ever questioned.\n\nRecord: Poster placement checklist",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the completed audit",
          "why": "A dated audit log is what demonstrates due diligence if the posting is ever questioned."
        },
        {
          "detail": "Poster audit complete",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Poster audit complete"
        },
        {
          "detail": "Obtain the current federal and state versions (free from the issuing agencies) and replace the outdated ones in the same visible location.\n\nWhy: Federal and California poster sets are available at no cost from the issuing agencies; there is no need to pay for a subscription poster service.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Order and post current versions",
          "why": "Federal and California poster sets are available at no cost from the issuing agencies; there is no need to pay for a subscription poster service."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Required federal and state workplace poster audit and annual update — January of each year, or a minimum-wage or leave law changes.",
      "title": "Required federal and state workplace poster audit and annual update",
      "trigger": "January of each year, or a minimum-wage or leave law changes",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California pay transparency and equal pay considerations relevant to compensation discussion (Labor Code §432.3, §1197.5)",
          "source": "California pay transparency and equal pay considerations relevant to compensation discussion (Labor Code §432.3, §1197.5)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "annual",
      "id": "hrc-014",
      "kind": "operational",
      "materials": [
        "Performance review form",
        "Prior year's review and goals",
        "Compensation benchmark reference",
        "Self-assessment form (employee-completed)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the anniversary date or the practice's fixed annual cycle to confirm this review is due now.\n\nWhy: A predictable cycle keeps reviews from being skipped or done only when there is a problem, which itself creates unfairness.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the employee's review due date",
          "why": "A predictable cycle keeps reviews from being skipped or done only when there is a problem, which itself creates unfairness."
        },
        {
          "detail": "Give the employee the self-assessment form at least a week before the scheduled conversation, asking them to rate their own performance and note goals.\n\nWhy: A self-assessment surfaces the employee's own perspective before the manager's view is presented, making the conversation more of a dialogue.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Send the employee a self-assessment form",
          "why": "A self-assessment surfaces the employee's own perspective before the manager's view is presented, making the conversation more of a dialogue."
        },
        {
          "detail": "Complete the performance review form with specific, dated examples for each rated area, referencing the prior year's goals.\n\nWhy: Specific examples are more useful to the employee and more defensible than general ratings if compensation or promotion decisions are later questioned.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft the manager's review",
          "why": "Specific examples are more useful to the employee and more defensible than general ratings if compensation or promotion decisions are later questioned."
        },
        {
          "detail": "Is a compensation change being considered?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-change",
              "label": "No compensation change this cycle"
            },
            {
              "goto": "s9",
              "id": "change-considered",
              "label": "Compensation change being considered"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is a compensation change being considered?"
        },
        {
          "detail": "Walk through the self-assessment and manager review together, discuss any compensation decision, and agree on goals for the coming year.\n\nWhy: A two-way conversation, rather than a one-way delivery of the written review, is what makes the goals for next year land.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hold the review conversation",
          "why": "A two-way conversation, rather than a one-way delivery of the written review, is what makes the goals for next year land."
        },
        {
          "detail": "Ask the employee to sign acknowledging the review was discussed (signature does not have to mean agreement with every rating).\n\nWhy: A signature documents that the conversation happened, which matters more than whether the employee agreed with every point.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Have both parties sign the completed review",
          "why": "A signature documents that the conversation happened, which matters more than whether the employee agreed with every point."
        },
        {
          "detail": "File the signed review in the personnel file and note next year's goals for reference at the next cycle.\n\nWhy: Filing next year's goals now is what makes next year's review efficient instead of starting from a blank page.\n\nRecord: Personnel file, performance review form",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "File the review and update the goal tracker",
          "why": "Filing next year's goals now is what makes next year's review efficient instead of starting from a blank page."
        },
        {
          "detail": "Annual review complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Annual review complete"
        },
        {
          "detail": "Compare the proposed pay to the practice's own benchmark reference for the role and experience level, and check it does not create an unexplained gap with employees of the same role.\n\nWhy: California equal-pay law (Labor Code §1197.5) requires pay differences for substantially similar work to be justified by seniority, merit, quantity/quality of production, or another bona fide factor.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Check the proposed change against role/experience benchmarks",
          "why": "California equal-pay law (Labor Code §1197.5) requires pay differences for substantially similar work to be justified by seniority, merit, quantity/quality of production, or another bona fide factor."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Annual performance review and compensation discussion — The anniversary date or annual cycle.",
      "title": "Annual performance review and compensation discussion",
      "trigger": "The anniversary date or annual cycle",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California FEHA/CFRA protected-leave floor relevant to distinguishing a protected absence from an unexcused no-show (Gov. Code §12945.2)",
          "source": "California FEHA/CFRA protected-leave floor relevant to distinguishing a protected absence from an unexcused no-show (Gov. Code §12945.2)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "generic",
          "label": "Generic office attendance policy — no specific public statute governs the coverage/welfare-check procedure itself beyond the protected-leave floor above — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic office attendance policy — no specific public statute governs the coverage/welfare-check procedure itself beyond the protected-leave floor above"
          },
          "source": "Generic office attendance policy — no specific public statute governs the coverage/welfare-check procedure itself beyond the protected-leave floor above — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-015",
      "kind": "operational",
      "materials": [
        "Emergency contact list",
        "Day's schedule",
        "Coverage call-list",
        "No-call no-show incident log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "scheduler",
        "all-staff",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Wait until 15 minutes after the scheduled shift start with no arrival and no call, text or message from the employee.\n\nWhy: A short grace period avoids overreacting to routine traffic or a late alarm while still catching a genuine no-show quickly.",
          "id": "s1",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 900,
          "title": "Confirm the 15-minute grace period has passed",
          "why": "A short grace period avoids overreacting to routine traffic or a late alarm while still catching a genuine no-show quickly."
        },
        {
          "detail": "Call and text the employee's primary number; if no response within a few minutes, call the emergency contact on file.\n\nWhy: Direct contact resolves the majority of no-shows quickly (overslept, car trouble, forgot the schedule) before any escalation is needed.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Attempt to contact the employee directly",
          "why": "Direct contact resolves the majority of no-shows quickly (overslept, car trouble, forgot the schedule) before any escalation is needed."
        },
        {
          "detail": "Did the employee or their emergency contact respond?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "responded",
              "label": "Employee or contact responded with an explanation"
            },
            {
              "goto": "s9",
              "id": "no-response",
              "label": "No response from employee or emergency contact"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the employee or their emergency contact respond?"
        },
        {
          "detail": "Record what the employee or emergency contact said, and whether it fell under a protected leave reason (illness, family emergency) or a routine no-show.\n\nWhy: Distinguishing a protected-leave reason from an unexcused no-show matters before any discipline decision is made.\n\nRecord: No-call no-show incident log",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the reason given",
          "why": "Distinguishing a protected-leave reason from an unexcused no-show matters before any discipline decision is made."
        },
        {
          "detail": "Give the scheduler the missing role, the shift time, and the day's booked schedule so they can start the coverage call-list or adjust bookings.\n\nWhy: Patient care and scheduled appointments cannot wait on resolving the reason for the absence — coverage is a parallel track, not a sequential one.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the day's coverage need to the scheduler",
          "why": "Patient care and scheduled appointments cannot wait on resolving the reason for the absence — coverage is a parallel track, not a sequential one."
        },
        {
          "detail": "Record the date, shift, time contact was attempted, outcome, and whether coverage was secured, for the employee's attendance record.\n\nWhy: A pattern of no-call no-shows is what supports progressive discipline later; a single entry without a pattern usually should not.\n\nRecord: No-call no-show incident log",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete the no-call no-show incident log entry",
          "why": "A pattern of no-call no-shows is what supports progressive discipline later; a single entry without a pattern usually should not."
        },
        {
          "detail": "Is this a repeat no-call no-show for this employee?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "first-time",
              "label": "First occurrence — no discipline action yet"
            },
            {
              "goto": "s10",
              "id": "repeat",
              "label": "Repeat occurrence — route to progressive discipline"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a repeat no-call no-show for this employee?"
        },
        {
          "detail": "No-call no-show handled",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "No-call no-show handled"
        },
        {
          "detail": "Is there a specific reason to worry about the employee's safety (e.g., known health condition, unusual silence after prior reliability)?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-specific-concern",
              "label": "No specific safety concern — continue as attendance issue"
            },
            {
              "goto": "s11",
              "id": "safety-concern",
              "label": "Genuine safety concern — consider a non-emergency welfare check via local police"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is there a specific reason to worry about the employee's safety (e.g., known health condition, unusual silence after prior reliability)?"
        },
        {
          "detail": "Give the office manager the incident log history so a written warning can be prepared under the progressive-discipline procedure.\n\nWhy: A repeat pattern, not a single event, is what should trigger formal discipline — the incident log is what proves the pattern.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the pattern to the progressive-discipline protocol",
          "why": "A repeat pattern, not a single event, is what should trigger formal discipline — the incident log is what proves the pattern."
        },
        {
          "detail": "Call the local police non-emergency line and request a welfare check at the employee's address on file, explaining the specific concern.\n\nWhy: A welfare check is a proportionate response when there is a specific reason to worry, distinct from routine attendance follow-up.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Request a non-emergency welfare check",
          "why": "A welfare check is a proportionate response when there is a specific reason to worry, distinct from routine attendance follow-up."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Employee no-call no-show at shift start — A scheduled team member has not arrived or called by 15 minutes after shift start.",
      "title": "Employee no-call no-show at shift start",
      "trigger": "A scheduled team member has not arrived or called by 15 minutes after shift start",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "State dental practice act staffing/supervision ratios for auxiliaries (varies by state; California Dental Board supervision levels for registered dental assistants and hygienists)",
          "source": "State dental practice act staffing/supervision ratios for auxiliaries (varies by state; California Dental Board supervision levels for registered dental assistants and hygienists)",
          "url": "https://www.dbc.ca.gov/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "hrc-016",
      "kind": "operational",
      "materials": [
        "Day's schedule",
        "Cross-training / role-coverage matrix",
        "Temp / float staffing agency contact list",
        "Patient reschedule script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "List which two or more team members are out, their roles, and which shifts are affected.\n\nWhy: The coverage plan depends entirely on which roles are missing — a missing hygienist is a different problem than a missing assistant or front-desk person.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm which roles and shifts are short-staffed",
          "why": "The coverage plan depends entirely on which roles are missing — a missing hygienist is a different problem than a missing assistant or front-desk person."
        },
        {
          "detail": "Does the shortage put the practice below the required supervision ratio for any scheduled clinical procedure?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "ratio-ok",
              "label": "Supervision ratios remain met"
            },
            {
              "goto": "s10",
              "id": "ratio-at-risk",
              "label": "Ratio at risk for one or more scheduled procedures"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the shortage put the practice below the required supervision ratio for any scheduled clinical procedure?"
        },
        {
          "detail": "Check which on-duty or on-call staff are cross-trained to cover the missing role for the day (e.g., a front-desk person trained on scheduling, a float assistant).",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the cross-training / role-coverage matrix for internal coverage"
        },
        {
          "detail": "Can internal cross-trained staff cover the gap?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "internal-covers",
              "label": "Internal coverage is sufficient"
            },
            {
              "goto": "s11",
              "id": "need-external",
              "label": "Internal coverage insufficient — call the float/temp agency list"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Can internal cross-trained staff cover the gap?"
        },
        {
          "detail": "Reassign cross-trained staff to the missing role for the day and confirm they understand the day's schedule changes.\n\nWhy: Using known, already-credentialed staff is lower-risk than bringing in someone unfamiliar with the practice's systems.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Reassign on-duty staff to cover the gap",
          "why": "Using known, already-credentialed staff is lower-risk than bringing in someone unfamiliar with the practice's systems."
        },
        {
          "detail": "Is full coverage secured for the day's booked schedule?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "full-coverage",
              "label": "Full coverage secured"
            },
            {
              "goto": "s12",
              "id": "partial-coverage",
              "label": "Only partial coverage possible — reduce the schedule"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is full coverage secured for the day's booked schedule?"
        },
        {
          "detail": "Brief the team on who is covering which role and any schedule changes before patients start arriving.\n\nWhy: A team that finds out about coverage changes mid-shift is more likely to make mistakes than one briefed at the start of the day.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the full team of the day's coverage plan",
          "why": "A team that finds out about coverage changes mid-shift is more likely to make mistakes than one briefed at the start of the day."
        },
        {
          "detail": "Record which roles were short, how coverage was arranged, and any appointments rescheduled, for staffing-pattern review.\n\nWhy: A pattern of shortages on the same days or roles is a planning signal for the practice owner, not just a one-off inconvenience.\n\nRecord: Staffing shortage log",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the shortage and how it was covered",
          "why": "A pattern of shortages on the same days or roles is a planning signal for the practice owner, not just a one-off inconvenience."
        },
        {
          "detail": "Coverage plan executed",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Coverage plan executed"
        },
        {
          "detail": "Do not proceed with a procedure that would run below the required supervision ratio; the practice owner decides whether to reschedule the procedure or bring in coverage first.\n\nWhy: Proceeding below a state-mandated supervision ratio risks a licensing violation for the practice, not just a scheduling inconvenience.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate to the practice owner before proceeding with any at-risk procedure.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Escalate to the practice owner before proceeding with any at-risk procedure",
          "why": "Proceeding below a state-mandated supervision ratio risks a licensing violation for the practice, not just a scheduling inconvenience."
        },
        {
          "detail": "Call the practice's pre-arranged temp/float agency or per-diem contacts in order until coverage is confirmed for the shift.\n\nWhy: Having a pre-arranged list ready before a shortage happens is what turns an emergency scramble into a known process.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Call the temp or float staffing agency list",
          "why": "Having a pre-arranged list ready before a shortage happens is what turns an emergency scramble into a known process."
        },
        {
          "detail": "Prioritize keeping urgent and pain-related appointments; identify the lowest-priority routine appointments to move to another day.\n\nWhy: When full coverage cannot be secured, reducing volume protects the appointments that matter most rather than running every chair short-handed.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify which appointments to reschedule",
          "why": "When full coverage cannot be secured, reducing volume protects the appointments that matter most rather than running every chair short-handed."
        },
        {
          "detail": "Give the front desk the list of appointments to move and the reschedule script to call patients as early in the day as possible.\n\nWhy: Calling patients as early as possible, rather than waiting until their arrival time, is what preserves goodwill when a reschedule is unavoidable.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the reschedule list to the front desk",
          "why": "Calling patients as early as possible, rather than waiting until their arrival time, is what preserves goodwill when a reschedule is unavoidable."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Unexpected staffing shortage — temporary coverage plan — Two or more team members are out on the same day.",
      "title": "Unexpected staffing shortage — temporary coverage plan",
      "trigger": "Two or more team members are out on the same day",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Fair Labor Standards Act and exemptions 29 CFR Part 541; FMLA 29 CFR Part 825; Title VII / EEOC harassment guidance; ADA Title I",
          "source": "Fair Labor Standards Act and exemptions 29 CFR Part 541; FMLA 29 CFR Part 825; Title VII / EEOC harassment guidance; ADA Title I",
          "url": "https://www.ecfr.gov/current/title-29/part-541"
        },
        {
          "kind": "statute",
          "label": "California Labor Code and IWC Wage Orders (general employment floor)",
          "source": "California Labor Code and IWC Wage Orders (general employment floor)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "generic",
          "label": "Reasonable-suspicion impairment removal-from-duty and fitness-for-duty testing, tied to a written employer policy and applicable state law — generic HR practice, no institute program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Reasonable-suspicion impairment removal-from-duty and fitness-for-duty testing, tied to a written employer policy and applicable state law — generic HR practice, no institute program reproduced"
          },
          "source": "Reasonable-suspicion impairment removal-from-duty and fitness-for-duty testing, tied to a written employer policy and applicable state law — generic HR practice, no institute program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "hrc-017",
      "kind": "operational",
      "materials": [
        "confidential personnel file",
        "written drug-and-alcohol / fitness-for-duty policy",
        "rideshare or transport arrangement",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "office-manager",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Note the exact signs observed — slurred speech, odor of alcohol, unsteady gait, erratic or uncharacteristic behavior — with the time and who else witnessed it. Do not confront the employee in front of patients.\n\nWhy: Contemporaneous, specific observations from more than one witness protect the practice if the situation is later disputed or challenged.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Observe and document specifically",
          "why": "Contemporaneous, specific observations from more than one witness protect the practice if the situation is later disputed or challenged."
        },
        {
          "detail": "Check for red-flag signs that point to a medical emergency rather than substance impairment: unresponsiveness, difficulty breathing, one-sided weakness or facial drooping, known diabetic condition, seizure activity, or chest pain.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "medical",
              "label": "Possible medical emergency — red-flag sign present"
            },
            {
              "advised": false,
              "goto": "s4",
              "id": "not-medical",
              "label": "No red-flag signs — proceed as a possible impairment situation"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Could this be a medical emergency rather than impairment?"
        },
        {
          "detail": "Call 911 immediately if the team member is unresponsive, having difficulty breathing, shows one-sided weakness or facial drooping, is a known diabetic in crisis, or is having a seizure — treat this as a medical emergency before assuming impairment. Stay with them and follow dispatcher instructions until EMS arrives.\n\nWhy: The presenting signs of impairment (slurred speech, unsteadiness, erratic behavior) overlap with stroke, hypoglycemia, seizure aftermath and other medical emergencies; ruling out an emergency comes before the fitness-for-duty process.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 first.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "any staff member present",
          "title": "Call 911 first",
          "why": "The presenting signs of impairment (slurred speech, unsteadiness, erratic behavior) overlap with stroke, hypoglycemia, seizure aftermath and other medical emergencies; ruling out an emergency comes before the fitness-for-duty process."
        },
        {
          "detail": "Is the employee mid-procedure with a patient?",
          "forks": [
            {
              "advised": false,
              "goto": "s15",
              "id": "yes",
              "label": "Yes — actively treating or assisting a patient"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "no",
              "label": "No active patient involvement"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the employee mid-procedure with a patient?"
        },
        {
          "detail": "Pull the employee from any clinical, driving, or safety-sensitive task right away, regardless of how the conversation goes.\n\nWhy: An impaired team member near patients, sharps, or a vehicle is an immediate safety risk that cannot wait for a full investigation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Remove from duty pending assessment.",
            "role": "practice owner or on-site senior clinician",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Remove from duty pending assessment",
          "why": "An impaired team member near patients, sharps, or a vehicle is an immediate safety risk that cannot wait for a full investigation."
        },
        {
          "detail": "Pull the employee aside privately, state the specific observations made, and ask directly whether they are able to safely continue working today.\n\nWhy: Fair process means giving the employee a chance to respond before any action is taken.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Have a private conversation",
          "why": "Fair process means giving the employee a chance to respond before any action is taken."
        },
        {
          "detail": "How does the employee respond?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "admits-or-continues",
              "label": "Admits impairment, refuses to answer, or signs persist"
            },
            {
              "advised": false,
              "goto": "s16",
              "id": "disputes",
              "label": "Disputes it and appears fine"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "How does the employee respond?"
        },
        {
          "detail": "Arrange a ride home or a rideshare at the practice's expense. Never let the employee drive themselves.\n\nWhy: Removing the immediate safety risk takes priority over the paperwork.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange safe transport home",
          "why": "Removing the immediate safety risk takes priority over the paperwork."
        },
        {
          "detail": "Consult the practice's written drug-and-alcohol / fitness-for-duty policy and, if the practice maintains a reasonable-suspicion testing program, offer or require testing per that policy and applicable state law.\n\nWhy: Acting on a written, consistently-applied policy — rather than an ad hoc decision — protects both the employee and the practice.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Apply the written fitness-for-duty policy",
          "why": "Acting on a written, consistently-applied policy — rather than an ad hoc decision — protects both the employee and the practice."
        },
        {
          "detail": "Record the date/time, specific observations, witnesses, actions taken, and outcome in the confidential personnel file, separate from the general employee file.\n\nRecord: Confidential incident log entry: date, observations, witnesses, action taken, testing offered/declined, outcome.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Log the incident confidentially"
        },
        {
          "detail": "Hold the employee out of scheduled patient-care duty pending a documented fitness-for-duty determination.",
          "id": "s11",
          "kind": "timer",
          "role": "practice-owner",
          "timer_seconds": 86400,
          "title": "Hold pending fitness-for-duty determination"
        },
        {
          "detail": "Is the employee cleared to return?",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "cleared",
              "label": "Cleared to return to normal duty"
            },
            {
              "advised": false,
              "goto": "s17",
              "id": "not-cleared",
              "label": "Not cleared, or policy violation confirmed"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is the employee cleared to return?"
        },
        {
          "detail": "Reinstate the employee with a documented conversation about expectations going forward and any policy consequence short of termination.\n\nWhy: A documented conversation closes the loop and sets a clear standard for the future.",
          "id": "s13",
          "kind": "step",
          "role": "hr",
          "title": "Reinstate with a documented conversation",
          "why": "A documented conversation closes the loop and sets a clear standard for the future."
        },
        {
          "detail": "Incident closed",
          "id": "s14",
          "kind": "step",
          "title": "Incident closed"
        },
        {
          "detail": "Immediately reassign the patient to another licensed or credentialed team member; tell the patient only that there is a staffing change, without disclosing suspicion.\n\nWhy: Patient safety and continuity come before the HR conversation.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off patient care to another provider",
          "why": "Patient safety and continuity come before the HR conversation."
        },
        {
          "detail": "If two or more independent observers noted the same specific signs, document the situation as reasonable suspicion even though the employee disputes it, and proceed to the policy step.\n\nWhy: Multiple independent, specific observations are the standard the practice's policy should rely on, not a single person's impression.",
          "id": "s16",
          "kind": "step",
          "role": "practice-owner",
          "title": "Document as reasonable suspicion if corroborated",
          "why": "Multiple independent, specific observations are the standard the practice's policy should rely on, not a single person's impression."
        },
        {
          "detail": "Hand off to the practice's disciplinary or termination process, and to counsel if the situation involves a protected leave or accommodation question (e.g., a disclosed substance-use disorder).",
          "id": "s17",
          "kind": "step",
          "role": "hr",
          "title": "Escalate to the disciplinary process"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Team member appears impaired by alcohol or drugs on duty — A staff member shows slurred speech, unsteadiness, odor of alcohol or erratic behavior during the shift.",
      "title": "Team member appears impaired by alcohol or drugs on duty",
      "trigger": "A staff member shows slurred speech, unsteadiness, odor of alcohol or erratic behavior during the shift",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California SB 553 Workplace Violence Prevention (Labor Code §6401.9)",
          "source": "California SB 553 Workplace Violence Prevention (Labor Code §6401.9)",
          "url": "https://calcivilrights.ca.gov/shpt/"
        },
        {
          "kind": "statute",
          "label": "California FEHA (Gov. Code §12940 et seq.) — retaliation protections apply to anyone reporting or involved in an incident",
          "source": "California FEHA (Gov. Code §12940 et seq.) — retaliation protections apply to anyone reporting or involved in an incident",
          "url": "https://calcivilrights.ca.gov/shpt/"
        },
        {
          "kind": "generic",
          "label": "911 / EMS as the first response to any active threat, weapon, injury, or violence in progress — universal public emergency-services floor — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "911 / EMS as the first response to any active threat, weapon, injury, or violence in progress — universal public emergency-services floor"
          },
          "source": "911 / EMS as the first response to any active threat, weapon, injury, or violence in progress — universal public emergency-services floor — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hrc-018",
      "kind": "operational",
      "materials": [
        "posted evacuation/shelter plan",
        "SB 553 Workplace Violence Prevention Plan log",
        "front-desk safety-screening flag list",
        "EAP referral information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "practice-owner",
        "hr",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Call 911 immediately if there is an active threat, a weapon, an injury, or violence in progress. Evacuate or shelter in place per the practice's posted plan before doing anything else — do not stop to fill out paperwork or assess documentation while a threat is active.\n\nWhy: No HR process outranks getting people safe and getting EMS or police responding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 first",
          "why": "No HR process outranks getting people safe and getting EMS or police responding."
        },
        {
          "detail": "Once safe, account for all staff and patients present, direct anyone in immediate danger away from the area, and do not let anyone reenter until cleared by responding officers.\n\nWhy: A headcount confirms no one is missing or hurt and unaccounted for.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Secure the area and account for everyone",
          "why": "A headcount confirms no one is missing or hurt and unaccounted for."
        },
        {
          "detail": "Are EMS or police on scene?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "responders-on-scene",
              "label": "EMS/police responding or on scene"
            },
            {
              "advised": false,
              "goto": "s13",
              "id": "threat-only",
              "label": "Credible threat only, resolved before responders needed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are EMS or police on scene?"
        },
        {
          "detail": "Hand off the scene to responding officers/EMS, provide the names of the involved parties, designate a single point of contact, and follow their instructions on securing the area as a scene.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hand the scene to responding officers"
        },
        {
          "detail": "Before resuming normal operations, assess whether the threat could recur this shift or day, and whether a restraining order, changed locks, or a law-enforcement escort is needed.\n\nWhy: Reopening the schedule without this check risks the same person returning.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Assess whether the threat could recur today.",
            "role": "practice owner with HR",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Assess whether the threat could recur today",
          "why": "Reopening the schedule without this check risks the same person returning."
        },
        {
          "detail": "Confirm the written Workplace Violence Prevention Plan log entry is opened for this incident, including: date/time/location, description, witnesses, weapon or injury involved, response taken, corrective action.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Open the SB 553 plan log entry"
        },
        {
          "detail": "Offer any injured or threatened employee time off, an EAP referral if available, and ask whether they want law-enforcement involvement documented for a possible workplace restraining order.\n\nWhy: The people affected need support, not just a completed log entry.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Care for those involved",
          "why": "The people affected need support, not just a completed log entry."
        },
        {
          "detail": "Where did the threat originate?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "employee-source",
              "label": "Coworker or an employee's ex-partner/associate"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "outside-source",
              "label": "Patient or outside visitor"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "hr",
          "title": "Where did the threat originate?"
        },
        {
          "detail": "Hand off to the practice's harassment/violence complaint intake and investigation process, including any needed safety plan such as parking or schedule changes.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Hand off to the harassment/violence investigation process"
        },
        {
          "detail": "Complete the SB 553 incident log entry, note corrective actions taken (training refresh, physical security change, escort protocol), and file it in the compliance record.\n\nRecord: Completed SB 553 Workplace Violence Prevention Plan log entry with corrective action.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Close out the SB 553 log"
        },
        {
          "detail": "Hold a post-incident review within 3 business days with anyone involved and adjust the written plan if a gap is found.",
          "id": "s11",
          "kind": "timer",
          "role": "practice-owner",
          "timer_seconds": 259200,
          "title": "Hold a post-incident review"
        },
        {
          "detail": "Incident closed",
          "id": "s12",
          "kind": "step",
          "title": "Incident closed"
        },
        {
          "detail": "Separate the parties and remove the individual making the threat from the premises (dismiss the patient or send the employee home) without further confrontation.\n\nWhy: Ending contact between the parties is the fastest way to lower risk when no emergency response is needed.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Take the immediate non-emergency response",
          "why": "Ending contact between the parties is the fastest way to lower risk when no emergency response is needed."
        },
        {
          "detail": "Flag the visitor's or patient's account per practice policy for future scheduling, and notify other locations if multi-site.\n\nRecord: Front-desk safety-screening flag with the date and a factual, non-diagnostic description of what happened.",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag the individual's file for future safety screening"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Workplace violence incident or credible threat — A patient, visitor, ex-partner of an employee or coworker threatens or commits violence at the office — 911 first, then the incident log.",
      "title": "Workplace violence incident or credible threat",
      "trigger": "A patient, visitor, ex-partner of an employee or coworker threatens or commits violence at the office — 911 first, then the incident log",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code final-pay timing requirements; benefits continuation (COBRA / Cal-COBRA) obligations",
          "source": "California Labor Code final-pay timing requirements; benefits continuation (COBRA / Cal-COBRA) obligations",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "generic",
          "label": "Sequence and tone for notifying a team of a colleague's death, coordinating with the family, and offering grief support — generic HR practice, no institute program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Sequence and tone for notifying a team of a colleague's death, coordinating with the family, and offering grief support — generic HR practice, no institute program reproduced"
          },
          "source": "Sequence and tone for notifying a team of a colleague's death, coordinating with the family, and offering grief support — generic HR practice, no institute program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 480,
      "frequency": "as-needed",
      "id": "hrc-019",
      "kind": "operational",
      "materials": [
        "personnel file",
        "benefits carrier contact list",
        "EAP referral information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm the death through a reliable source (family, obituary, another employer if the person worked elsewhere) before any internal or external communication.\n\nWhy: Acting on an unconfirmed report risks a devastating, avoidable error.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Verify and confirm through a reliable source",
          "why": "Acting on an unconfirmed report risks a devastating, avoidable error."
        },
        {
          "detail": "Before telling the team, the owner and HR align on what will be said, who says it, and when — no announcement over a group text.\n\nWhy: An uncoordinated announcement can retraumatize the team and misstate facts the family hasn't confirmed for release.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Align leadership before telling the team.",
            "role": "practice owner",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Align leadership before telling the team",
          "why": "An uncoordinated announcement can retraumatize the team and misstate facts the family hasn't confirmed for release."
        },
        {
          "detail": "Tell the deceased's closest coworkers individually or in a small private setting first, then the wider team together, allowing time and space to react.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the closest coworkers privately first"
        },
        {
          "detail": "Reassign or reschedule the deceased team member's patients for the affected day(s) without disclosing the reason to patients beyond an unexpected staffing change.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Adjust the patient schedule"
        },
        {
          "detail": "Process final wages per state final-pay timing rules, identify any earned/unused PTO payout obligation, and notify the benefits carrier(s) — health, life, and retirement plan — to begin beneficiary claim processing.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Process final pay and benefits"
        },
        {
          "detail": "Designate one HR contact for the family to handle logistics — final paycheck, personal belongings, benefits paperwork — so the family isn't fielding multiple calls.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Designate one HR contact for the family"
        },
        {
          "detail": "Collect personal belongings from the workstation or locker and return them to the family through the HR contact, rather than leaving coworkers to sort through them.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect and return personal belongings"
        },
        {
          "detail": "Close the personnel file with the date noted as deceased, and process any COBRA/benefits-continuation notice for surviving dependents where applicable.\n\nRecord: Personnel file closed with date; benefits-continuation notice sent if dependents are affected.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Close out the personnel file"
        },
        {
          "detail": "Offer an EAP referral or grief resource to the team, and be flexible on schedule for those closest to the deceased.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Offer support resources to the team"
        },
        {
          "detail": "Does the family want a public acknowledgment?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "public-tribute",
              "label": "Family/team wants a public tribute or announcement"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "private",
              "label": "Family requests privacy, no public statement"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the family want a public acknowledgment?"
        },
        {
          "detail": "Coordinate any public acknowledgment — obituary link, card, memorial contribution — with the family's wishes before posting anything externally.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Coordinate the public tribute with the family"
        },
        {
          "detail": "Process closed",
          "id": "s12",
          "kind": "step",
          "title": "Process closed"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Death of a team member — The office learns that a current employee has died.",
      "title": "Death of a team member",
      "trigger": "The office learns that a current employee has died",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California Labor Commissioner wage-claim process; DFEH/CRD and EEOC charge processes",
          "source": "California Labor Commissioner wage-claim process; DFEH/CRD and EEOC charge processes",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "regulation",
          "label": "29 CFR Part 1601 (EEOC procedural regulations), specifically §1601.28 — notice of right to sue procedure; suit must be filed within 90 days of receipt of the notice",
          "repaired": {
            "action": "replace",
            "evidence": "The determination shall inform the person claiming to be aggrieved or the person on whose behalf a charge was filed of the right to sue in Federal district court within 90 days of receipt of the determination. ... Lawsuits under Title VII, the ADA or GINA must be filed in a federal or state court within 90 days of receipt of the notice of right to sue; or the right to sue based on that charge will be lost.",
            "ticket": "PROT-017",
            "was": {
              "source": "Title VII / EEOC charge process and right-to-sue procedure",
              "url": "https://www.ecfr.gov/current/title-29/part-541"
            }
          },
          "source": "29 CFR Part 1601 (subpart B), §1601.28",
          "url": "https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XIV/part-1601/subpart-B/subject-group-ECFR69236f603c54424/section-1601.28"
        },
        {
          "kind": "statute",
          "label": "California FEHA (Gov. Code §12940 et seq.) retaliation protections for anyone who filed or participated in a charge",
          "source": "California FEHA (Gov. Code §12940 et seq.) retaliation protections for anyone who filed or participated in a charge",
          "url": "https://calcivilrights.ca.gov/shpt/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "hrc-020",
      "kind": "operational",
      "materials": [
        "personnel file",
        "timekeeping and pay records",
        "policy manual in effect at the relevant time",
        "EPLI carrier / employment counsel contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "hr",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Record the date the notice was received, the agency (state labor commissioner, civil rights department, EEOC, or Department of Labor Wage & Hour), the case number, and the response deadline stated on the notice — deadlines are typically short and not automatically extendable.\n\nWhy: Missing a deadline can forfeit the practice's ability to respond at all.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Log receipt and the response deadline",
          "why": "Missing a deadline can forfeit the practice's ability to respond at all."
        },
        {
          "detail": "Do not contact the complaining employee about the charge, do not alter or create records related to it, and do not respond to the agency until the response has been reviewed — any communication becomes part of the record.\n\nWhy: An informal contact or an altered record can turn a defensible claim into a much harder one.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Do not respond without counsel.",
            "role": "compliance officer / practice owner",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Do not respond without counsel",
          "why": "An informal contact or an altered record can turn a defensible claim into a much harder one."
        },
        {
          "detail": "Engage employment counsel — or the practice's EPLI carrier's assigned counsel — before drafting any position statement or response. This sets the strategy and preserves privilege over the practice's internal discussions.\n\nWhy: A licensed attorney's involvement changes what is protected from discovery and how the response is framed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Engage employment counsel.",
            "role": "employment counsel",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Engage employment counsel",
          "why": "A licensed attorney's involvement changes what is protected from discovery and how the response is framed."
        },
        {
          "detail": "Issue a hold on all records related to the complaining employee — schedule, pay, personnel file, and relevant emails or texts. Nothing gets deleted or routinely purged while the matter is pending.\n\nWhy: Destroying records after a charge is received, even through routine purging, can create a separate legal problem.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Issue a litigation hold",
          "why": "Destroying records after a charge is received, even through routine purging, can create a separate legal problem."
        },
        {
          "detail": "Assemble the complete personnel file, timekeeping and pay records, the relevant policies in effect at the time, and any prior complaints or discipline involving the same parties, for counsel's review.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Assemble records for counsel"
        },
        {
          "detail": "Counsel prepares the position statement or response within the agency's deadline; the practice does not submit anything counsel has not reviewed.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Counsel drafts the response"
        },
        {
          "detail": "Confirm no scheduling, discipline, or treatment change toward the complaining employee is happening because of the charge.\n\nWhy: Retaliation is a separate claim that is often easier to prove than the underlying charge.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm no retaliation is occurring.",
            "role": "practice owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Confirm no retaliation is occurring",
          "why": "Retaliation is a separate claim that is often easier to prove than the underlying charge."
        },
        {
          "detail": "File the response by the deadline, record confirmation of filing, and calendar the agency's next expected step (investigation, mediation offer, right-to-sue letter).\n\nRecord: Filed response with confirmation, and a calendared next-step date.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "File the response and track next steps"
        },
        {
          "detail": "What is the next agency step?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "mediation",
              "label": "Agency offers early mediation or a settlement conference"
            },
            {
              "advised": false,
              "goto": "s13",
              "id": "investigation",
              "label": "Agency proceeds to a full investigation"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "practice-owner",
          "title": "What is the next agency step?"
        },
        {
          "detail": "Hand off participation decisions to counsel; the practice attends mediation only with counsel present or on counsel's advice.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hand off participation decisions to counsel"
        },
        {
          "detail": "Once resolved — dismissal, settlement, or a right-to-sue letter — record the outcome, and route any policy gap identified (for example, a missing wage-statement item) to the relevant HR protocol for correction.\n\nRecord: Case outcome and date; any policy-correction ticket opened.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Close out and route policy lessons"
        },
        {
          "detail": "Matter closed",
          "id": "s12",
          "kind": "step",
          "title": "Matter closed"
        },
        {
          "detail": "Respond to further agency information requests through counsel, within the stated deadlines.",
          "id": "s13",
          "kind": "step",
          "role": "hr",
          "title": "Cooperate with the investigation through counsel"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Wage-and-hour claim, labor-agency notice or EEOC / civil-rights charge received — A current or former employee files a wage claim, or a notice of charge or audit arrives from a labor or civil-rights agency.",
      "title": "Wage-and-hour claim, labor-agency notice or EEOC / civil-rights charge received",
      "trigger": "A current or former employee files a wage claim, or a notice of charge or audit arrives from a labor or civil-rights agency",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California licensure verification for auxiliaries",
          "source": "Dental Board of California licensure verification for auxiliaries",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "statute",
          "label": "California Labor Code and IWC Wage Orders (general employment floor for reassignment and pay during a duty restriction)",
          "source": "California Labor Code and IWC Wage Orders (general employment floor for reassignment and pay during a duty restriction)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "hrc-021",
      "kind": "operational",
      "materials": [
        "credential-tracking log",
        "primary-source license lookup access",
        "written scope-of-duty policy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager",
        "compliance-officer",
        "dentist",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "A lapse is detected either through the periodic license-verification check against the primary licensing board lookup, or a credential-tracking reminder passing its expiration date without renewal proof on file.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Detect the lapse"
        },
        {
          "detail": "Immediately restrict the individual from performing any duty that requires the lapsed credential — radiography without a current certificate, expanded-function duties without a current permit — until it is verified current. This is not optional pending paperwork catching up.\n\nWhy: Performing a credentialed duty without a valid credential is both a patient-safety and a licensing-compliance risk, regardless of how administrative the lapse looks.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Pull the duty from scope immediately.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Pull the duty from scope immediately",
          "why": "Performing a credentialed duty without a valid credential is both a patient-safety and a licensing-compliance risk, regardless of how administrative the lapse looks."
        },
        {
          "detail": "Check the primary-source license lookup — the state licensing board or the CPR-issuing body directly — rather than relying on the employee's own statement.\n\nWhy: A screenshot or a verbal assurance from the employee is not the same as confirming with the licensing authority.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify status at the primary source",
          "why": "A screenshot or a verbal assurance from the employee is not the same as confirming with the licensing authority."
        },
        {
          "detail": "What is the actual status?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "in-process",
              "label": "Administrative delay — renewal in process and confirmed"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "true-lapse",
              "label": "True lapse — expired, disciplined, or never held"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What is the actual status?"
        },
        {
          "detail": "Obtain written proof of the pending renewal or the corrected record, restore scope of duty, and update the credential-tracking file with the new expiration date.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm and restore scope"
        },
        {
          "detail": "Update the credentialing tracker with the verification date, the source checked, and the current expiration date for the next periodic review.\n\nRecord: Credential-tracking entry: verification date, source, new expiration date.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Update the credential file"
        },
        {
          "detail": "Set the next reminder well ahead of the new expiration date so the practice is not relying on the employee alone to notice.",
          "id": "s7",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 86400,
          "title": "Set the next review reminder"
        },
        {
          "detail": "Credential status resolved",
          "id": "s8",
          "kind": "step",
          "title": "Credential status resolved"
        },
        {
          "detail": "Notify the practice owner and the treating dentist that this individual cannot perform the affected duty until the credential is current, and that any prior work performed without a valid credential may need review.\n\nWhy: The treating dentist needs to know before relying on that person for a credentialed task, and any past work performed uncredentialed may carry its own review obligation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Notify practice leadership.",
            "role": "practice owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Notify practice leadership",
          "why": "The treating dentist needs to know before relying on that person for a credentialed task, and any past work performed uncredentialed may carry its own review obligation."
        },
        {
          "detail": "Reassign the individual to duties that do not require the lapsed credential, or adjust the schedule so a currently-credentialed team member covers the gap.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Reassign duties"
        },
        {
          "detail": "Hand off to the employee a clear renewal plan and deadline; note that continued failure to renew may lead to further HR action per the practice's credentialing policy.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Hand the employee a renewal plan"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Auxiliary or hygienist license, radiography certificate or CPR card has lapsed — A credential expiration date passes, or a verification check shows a lapsed or disciplined license.",
      "title": "Auxiliary or hygienist license, radiography certificate or CPR card has lapsed",
      "trigger": "A credential expiration date passes, or a verification check shows a lapsed or disciplined license",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and IWC Wage Orders (general employment floor for lawful, reasonable job instructions and discipline)",
          "source": "California Labor Code and IWC Wage Orders (general employment floor for lawful, reasonable job instructions and discipline)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "generic",
          "label": "Structured conflict-resolution and progressive-discipline sequencing — generic HR practice, no institute program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Structured conflict-resolution and progressive-discipline sequencing — generic HR practice, no institute program reproduced"
          },
          "source": "Structured conflict-resolution and progressive-discipline sequencing — generic HR practice, no institute program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hrc-022",
      "kind": "operational",
      "materials": [
        "progressive-discipline policy",
        "conflict-resolution note template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "If the conflict is happening in the moment, separate the individuals and move the conversation away from the operatory or front desk where patients or other staff can overhear.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Separate and de-escalate"
        },
        {
          "detail": "Talk to each person involved separately and factually — what happened, when, and who else was present — before forming a conclusion.\n\nWhy: Forming a conclusion before hearing both accounts risks an unfair or inaccurate response.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Hear both sides separately",
          "why": "Forming a conclusion before hearing both accounts risks an unfair or inaccurate response."
        },
        {
          "detail": "Does this involve a policy violation?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "policy-violation",
              "label": "Insubordination, refusal of a reasonable instruction, or harassment-adjacent language"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "friction-only",
              "label": "A personality or communication conflict with no policy violation"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does this involve a policy violation?"
        },
        {
          "detail": "Before issuing any formal discipline, confirm the instruction given was reasonable, lawful, and within the employee's job duties, and that the employee's account has been heard.\n\nWhy: Discipline issued on an instruction that wasn't actually reasonable or within scope can itself become a problem.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Review before issuing discipline.",
            "role": "practice owner or office manager with HR",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Review before issuing discipline",
          "why": "Discipline issued on an instruction that wasn't actually reasonable or within scope can itself become a problem."
        },
        {
          "detail": "Issue the response called for by the practice's progressive-discipline policy — verbal coaching or a written warning — and document what was said, by whom, and the expected change going forward.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Issue the documented response"
        },
        {
          "detail": "Note the date, the issue, and the resolution or discipline in the appropriate file — the personnel file for formal discipline, or a lighter conflict-resolution note otherwise.\n\nRecord: Date, issue summary, and outcome (discipline or agreed adjustments).",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Log the outcome"
        },
        {
          "detail": "Check in after two weeks to confirm the friction hasn't recurred or escalated.",
          "id": "s7",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1209600,
          "title": "Follow up in two weeks"
        },
        {
          "detail": "Resolved and followed up",
          "id": "s8",
          "kind": "step",
          "title": "Resolved and followed up"
        },
        {
          "detail": "Bring the two team members together for a structured conversation focused on the specific work friction — scheduling, communication style, shared tasks — rather than personalities.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Facilitate a structured conversation"
        },
        {
          "detail": "Agree on one or two concrete working adjustments (who confirms handoffs, how disagreements get raised) and set a follow-up date to check whether it worked.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Agree on concrete working adjustments"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Interpersonal conflict or insubordination between team members — Two team members refuse to work together, or an employee openly refuses a reasonable instruction.",
      "title": "Interpersonal conflict or insubordination between team members",
      "trigger": "Two team members refuse to work together, or an employee openly refuses a reasonable instruction",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §1030–§1033 lactation accommodation (private, non-bathroom space and reasonable break time)",
          "source": "California Labor Code §1030–§1033 lactation accommodation (private, non-bathroom space and reasonable break time)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "California IWC Wage Order 4 (break-time interaction) and Labor Code §226 (wage statement accuracy where breaks affect pay)",
          "source": "California IWC Wage Order 4 (break-time interaction) and Labor Code §226 (wage statement accuracy where breaks affect pay)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "hrc-023",
      "kind": "operational",
      "materials": [
        "private, non-bathroom lactation space",
        "refrigeration option for stored milk",
        "adjusted daily schedule"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Acknowledge the request promptly and confirm the employee's expected return date and the anticipated need duration — accommodation is generally needed for as long as the employee is nursing.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Acknowledge the request promptly"
        },
        {
          "detail": "Identify a location that is not a bathroom, is shielded from view, is free from intrusion, and has a place to sit and a nearby electrical outlet.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify a compliant space"
        },
        {
          "detail": "Confirm the space and break arrangement meet the applicable lactation-accommodation requirements — a private, non-bathroom space and reasonable break time, which may run concurrently with existing paid breaks but is unpaid if it extends beyond them — before telling the employee it's ready.\n\nWhy: Verifying compliance before the employee's first day back avoids a rushed, non-compliant workaround.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm space and break-time compliance.",
            "role": "compliance officer or office manager",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm space and break-time compliance",
          "why": "Verifying compliance before the employee's first day back avoids a rushed, non-compliant workaround."
        },
        {
          "detail": "Adjust the daily schedule to build in lactation break windows without leaving the chairside or front desk uncovered — coordinate coverage in advance rather than leaving it to the moment.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Adjust the daily schedule"
        },
        {
          "detail": "Confirm the space, schedule, and any refrigeration option for stored milk with the employee, and give a way to report a problem — such as the space being unavailable that day — without penalty.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Confirm the arrangement with the employee"
        },
        {
          "detail": "Record the accommodation provided — space and break pattern — in the personnel file, separate from any underlying medical detail.\n\nRecord: Accommodation summary: space assigned, break pattern, start date.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Document the accommodation"
        },
        {
          "detail": "Does the practice believe the standard accommodation creates a genuine hardship?",
          "forks": [
            {
              "advised": false,
              "goto": "s10",
              "id": "hardship-claim",
              "label": "Genuine hardship believed (e.g., a single small suite)"
            },
            {
              "advised": true,
              "goto": "s8",
              "id": "workable",
              "label": "Standard accommodation is workable"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the practice believe the standard accommodation creates a genuine hardship?"
        },
        {
          "detail": "Check in at 30 days to confirm the arrangement is still working as the employee's needs or schedule change.",
          "id": "s8",
          "kind": "timer",
          "role": "hr",
          "timer_seconds": 2592000,
          "title": "Check in at 30 days"
        },
        {
          "detail": "Accommodation in place",
          "id": "s9",
          "kind": "step",
          "title": "Accommodation in place"
        },
        {
          "detail": "An undue-hardship exception is narrow and must be documented with specifics before being relied on — get it reviewed rather than assuming the space genuinely qualifies.\n\nWhy: Hardship exceptions are easy to claim and hard to justify after the fact; a documented review protects both the employee and the practice.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Review any hardship exception.",
            "role": "compliance officer with counsel",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Review any hardship exception",
          "why": "Hardship exceptions are easy to claim and hard to justify after the fact; a documented review protects both the employee and the practice."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Lactation accommodation: break time and private space — A team member returning from leave asks to express milk during the workday.",
      "title": "Lactation accommodation: break time and private space",
      "trigger": "A team member returning from leave asks to express milk during the workday",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §230 (jury duty and witness leave protections)",
          "source": "California Labor Code §230 (jury duty and witness leave protections)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "California Elections Code §14000 (paid time off to vote, up to two hours, employer may designate start or end of shift)",
          "source": "California Elections Code §14000 (paid time off to vote, up to two hours, employer may designate start or end of shift)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-024",
      "kind": "operational",
      "materials": [
        "jury summons or subpoena copy",
        "personnel file",
        "patient schedule"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Collect the jury summons, subpoena, or voting-leave request and note the date(s) needed.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and log the documentation"
        },
        {
          "detail": "Approve the leave — jury duty, witness subpoena, and voting leave are protected. The practice may not require the employee to use PTO for jury or witness duty where state law prohibits it, and may not discipline or threaten the employee for taking it.\n\nWhy: These leave types are legally protected regardless of how the schedule is affected.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Approve without retaliation.",
            "role": "office manager",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "office-manager",
          "title": "Approve without retaliation",
          "why": "These leave types are legally protected regardless of how the schedule is affected."
        },
        {
          "detail": "What type of leave is this?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "jury-witness",
              "label": "Jury duty or witness subpoena"
            },
            {
              "advised": false,
              "goto": "s8",
              "id": "voting",
              "label": "Voting leave"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "What type of leave is this?"
        },
        {
          "detail": "Ask for proof of service or completion for payroll purposes — many states require unpaid jury leave, some require pay for a limited number of days — and reschedule the employee's patients for the date(s) needed.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Verify and reschedule patients"
        },
        {
          "detail": "Confirm with the employee when jury service ends each day or week, since on-call jury duty can extend unpredictably, and keep the schedule flexible until release.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Confirm the return date as service continues"
        },
        {
          "detail": "Record the leave type, dates, pay treatment, and any proof of service or voting received in the personnel file.\n\nRecord: Leave type, dates, pay treatment, and supporting documentation on file.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Document the leave"
        },
        {
          "detail": "Leave request resolved",
          "id": "s7",
          "kind": "step",
          "title": "Leave request resolved"
        },
        {
          "detail": "Confirm that time off to vote is provided if the employee doesn't have sufficient time outside working hours (generally up to two hours), taken only at the start or end of the shift as the practice designates, with two working days' advance notice where feasible.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the voting-leave time entitlement"
        },
        {
          "detail": "Adjust the schedule to grant the requested voting window at the start or end of shift per the employee's choice and the practice's designation rule.",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Schedule the voting window"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Jury duty, witness and voting leave request — An employee presents a jury summons, subpoena or asks for time to vote.",
      "title": "Jury duty, witness and voting leave request",
      "trigger": "An employee presents a jury summons, subpoena or asks for time to vote",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and Wage Order provisions",
          "source": "California Labor Code and Wage Order provisions",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "California Government Code §12945.7 — bereavement leave (up to 5 days per loss, unpaid unless employee elects accrued leave)",
          "source": "California Government Code §12945.7 — bereavement leave (up to 5 days per loss, unpaid unless employee elects accrued leave)",
          "url": "https://leginfo.legislature.ca.gov/faces/codesTOCSelected.xhtml?tocCode=GOV"
        },
        {
          "kind": "statute",
          "label": "California Government Code §12945.6 — reproductive loss leave (miscarriage, failed adoption or surrogacy, stillbirth, unsuccessful assisted reproduction)",
          "source": "California Government Code §12945.6 — reproductive loss leave (miscarriage, failed adoption or surrogacy, stillbirth, unsuccessful assisted reproduction)",
          "url": "https://leginfo.legislature.ca.gov/faces/codesTOCSelected.xhtml?tocCode=GOV"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hrc-025",
      "kind": "operational",
      "materials": [
        "leave request form",
        "employee handbook bereavement and reproductive-loss policy",
        "personnel file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Take the employee aside, express condolences plainly, and ask only how many days they need and when they want them to start. Do not ask for a death certificate, obituary, or medical documentation before granting leave.\n\nWhy: State law does not condition the leave on proof up front; asking for it first reads as gatekeeping grief and can itself be a compliance problem.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Acknowledge the request privately and without demanding proof",
          "why": "State law does not condition the leave on proof up front; asking for it first reads as gatekeeping grief and can itself be a compliance problem."
        },
        {
          "detail": "Check that the employee has completed any applicable minimum service period and that the loss falls within the covered categories (immediate family death, or miscarriage, stillbirth, failed adoption/surrogacy, unsuccessful assisted reproduction). Note the loss category in the request form, not clinical detail.\n\nWhy: Confirms which statute (bereavement vs reproductive-loss) governs the up-to-5-days floor so the record is accurate without over-collecting sensitive detail.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Confirm the statutory floor applies",
          "why": "Confirms which statute (bereavement vs reproductive-loss) governs the up-to-5-days floor so the record is accurate without over-collecting sensitive detail."
        },
        {
          "detail": "The employee chooses.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "unpaid",
              "label": "Unpaid leave under the statutory floor"
            },
            {
              "goto": "s4",
              "id": "pto",
              "label": "Employee elects to substitute accrued PTO or sick leave"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hr",
          "title": "Determine pay source for the leave days"
        },
        {
          "detail": "Before any manager suggests fewer days or asks for more justification, HR confirms the request is within the 5-day statutory floor per loss and that the employee — not the practice — chooses which days to use it on.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance check before shortening or questioning the request.",
            "role": "hr",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "hr",
          "title": "Compliance check before shortening or questioning the request"
        },
        {
          "detail": "Block the employee's shifts for the agreed days and flag the pay-period entry as bereavement/reproductive-loss leave with the chosen pay source.\n\nWhy: Keeps payroll and coverage planning accurate without the rest of the schedule needing to know the reason.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Enter the leave dates in the scheduling and payroll systems",
          "why": "Keeps payroll and coverage planning accurate without the rest of the schedule needing to know the reason."
        },
        {
          "detail": "Hand the scheduler the blocked dates only — role and shift impact, not the reason for the absence.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Notify the scheduler to arrange coverage"
        },
        {
          "detail": "Record the leave category, dates, and pay source in the personnel file. Store any documentation the employee voluntarily provided; do not note clinical or personal detail beyond what they chose to share.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "File the leave record"
        },
        {
          "detail": "A brief, low-key welcome-back on the employee's first day back; no requirement to discuss the loss further.\n\nWhy: Keeps the return to work supportive rather than an interrogation.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Check in on return without forcing disclosure",
          "why": "Keeps the return to work supportive rather than an interrogation."
        },
        {
          "detail": "Leave processed and documented",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Leave processed and documented"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Bereavement or reproductive-loss leave request — An employee reports a death in the family or a pregnancy loss and needs time off.",
      "title": "Bereavement or reproductive-loss leave request",
      "trigger": "An employee reports a death in the family or a pregnancy loss and needs time off",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and Wage Order provisions",
          "source": "California Labor Code and Wage Order provisions",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "regulation",
          "label": "ERISA 29 U.S.C. §1001 et seq.; ACA employer shared-responsibility rules; COBRA continuation coverage 29 U.S.C. §1161 et seq.",
          "source": "ERISA 29 U.S.C. §1001 et seq.; ACA employer shared-responsibility rules; COBRA continuation coverage 29 U.S.C. §1161 et seq.",
          "url": "https://www.dol.gov/general/topic/health-plans/cobra"
        },
        {
          "kind": "regulation",
          "label": "Federal special-enrollment-period rule for qualifying life events (30-day window), 26 CFR §54.9801-6",
          "source": "Federal special-enrollment-period rule for qualifying life events (30-day window), 26 CFR §54.9801-6",
          "url": "https://www.ecfr.gov/current/title-26/section-54.9801-6"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "annual",
      "id": "hrc-026",
      "kind": "operational",
      "materials": [
        "benefits summary plan description",
        "carrier enrollment portal or paper forms",
        "COBRA/continuation notice template",
        "premium deduction schedule"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Identify whether this is annual open enrollment or a qualifying life event",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "open",
              "label": "Annual open enrollment window"
            },
            {
              "goto": "s9",
              "id": "qle",
              "label": "Qualifying life event (marriage, birth, loss of other coverage, etc.)"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "hr",
          "title": "Identify whether this is annual open enrollment or a qualifying life event"
        },
        {
          "detail": "Distribute the summary plan description, coverage options, and the enrollment deadline to every eligible employee, with a reminder date set two weeks before close.\n\nWhy: A missed deadline can lock an employee out of coverage for a year, so early and repeated notice matters.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Announce the enrollment window to all eligible employees",
          "why": "A missed deadline can lock an employee out of coverage for a year, so early and repeated notice matters."
        },
        {
          "detail": "Have the employee complete carrier enrollment forms and submit any required dependent verification (marriage certificate, birth record, proof of prior coverage loss) before the deadline.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Collect elections and dependent documentation"
        },
        {
          "detail": "HR confirms every submitted election is within the enrollment or 30-day QLE window and that dependent documentation is complete before forwarding to the carrier.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Deadline and completeness check before submitting to the carrier.",
            "role": "hr",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "hr",
          "title": "Deadline and completeness check before submitting to the carrier"
        },
        {
          "detail": "File the enrollment with the carrier and adjust the next payroll cycle's premium deductions to match the new elections.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit elections to the carrier and update payroll deductions"
        },
        {
          "detail": "Did this event include a loss of coverage for someone leaving the plan?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-loss",
              "label": "No coverage loss involved"
            },
            {
              "goto": "s10",
              "id": "loss",
              "label": "Someone is losing coverage (termination, reduced hours, divorce, aging out)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "hr",
          "title": "Did this event include a loss of coverage for someone leaving the plan?"
        },
        {
          "detail": "Store the election form, dependent documentation, and (if sent) the COBRA notice date in the personnel file.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "File the enrollment record"
        },
        {
          "detail": "Enrollment or life-event change processed",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Enrollment or life-event change processed"
        },
        {
          "detail": "Record the event type and date, and tell the employee their election deadline (30 days from the event under the federal special-enrollment rule).\n\nWhy: Missing the 30-day window forfeits the mid-year election right; the deadline has to be stated, not assumed known.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Confirm the qualifying event and open the 30-day special enrollment window",
          "why": "Missing the 30-day window forfeits the mid-year election right; the deadline has to be stated, not assumed known."
        },
        {
          "detail": "Mail or deliver the continuation-coverage notice within the statutory deadline after the qualifying event, with the election deadline stated.\n\nWhy: A missed COBRA notice deadline is a common, expensive small-practice exposure.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Send the COBRA/continuation-coverage election notice",
          "why": "A missed COBRA notice deadline is a common, expensive small-practice exposure."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Employee benefits open enrollment and qualifying life events — The annual enrollment window opens, or an employee marries, has a child or loses other coverage.",
      "title": "Employee benefits open enrollment and qualifying life events",
      "trigger": "The annual enrollment window opens, or an employee marries, has a child or loses other coverage",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and Wage Order provisions",
          "source": "California Labor Code and Wage Order provisions",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "Federal-state unemployment insurance framework, FUTA 26 U.S.C. §3301 et seq.",
          "source": "Federal-state unemployment insurance framework, FUTA 26 U.S.C. §3301 et seq.",
          "url": "https://www.ecfr.gov/current/title-26"
        },
        {
          "kind": "regulation",
          "label": "State unemployment insurance agency claim-response deadline (e.g., California EDD Notice of Unemployment Insurance Claim, typically a 10-day response window)",
          "source": "State unemployment insurance agency claim-response deadline (e.g., California EDD Notice of Unemployment Insurance Claim, typically a 10-day response window)",
          "url": "https://edd.ca.gov/en/Unemployment/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-027",
      "kind": "operational",
      "materials": [
        "unemployment claim notice",
        "personnel file",
        "separation documentation",
        "response form or portal"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record the date the notice arrived, the claimant's name, and the state's stated response deadline (commonly around 10 days) in a tracked calendar entry.\n\nWhy: Missing the response window can mean the claim is decided without the practice's facts on record, regardless of merit.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Log the notice and its response deadline immediately",
          "why": "Missing the response window can mean the claim is decided without the practice's facts on record, regardless of merit."
        },
        {
          "detail": "Pull the personnel file: hire date, final pay period, reason for separation (voluntary resignation, layoff, termination for cause), and any documented performance or conduct record.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Gather the separation facts"
        },
        {
          "detail": "Determine whether to contest the claim",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-contest",
              "label": "Facts support eligibility — do not contest"
            },
            {
              "goto": "s4",
              "id": "contest",
              "label": "Facts support a contest (e.g., documented gross misconduct or voluntary quit without good cause)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hr",
          "title": "Determine whether to contest the claim"
        },
        {
          "detail": "Write the response using only documented facts and dates already on file — never characterize motive or add anything not previously recorded.\n\nWhy: A response inconsistent with the personnel file undermines credibility with the agency and can itself be treated as misrepresentation.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Draft a factual, dated response",
          "why": "A response inconsistent with the personnel file undermines credibility with the agency and can itself be treated as misrepresentation."
        },
        {
          "detail": "The practice owner reviews the drafted response against the personnel file before it is filed, since the response becomes part of a legal record.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review before the response is submitted.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review before the response is submitted"
        },
        {
          "detail": "File through the state portal or mail with delivery confirmation, before the stated deadline.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Submit the response before the deadline"
        },
        {
          "detail": "Store a copy of the notice, the response, and proof of timely submission (confirmation number or mail receipt) with the separation record.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "File the response and proof of submission"
        },
        {
          "detail": "Pass the state's eligibility determination and any appeal deadline to the practice owner as soon as it is received.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Notify the owner when the determination arrives"
        },
        {
          "detail": "Claim notice response filed",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Claim notice response filed"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Unemployment insurance claim notice response — The state sends a notice that a former employee filed for unemployment.",
      "title": "Unemployment insurance claim notice response",
      "trigger": "The state sends a notice that a former employee filed for unemployment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and Wage Order provisions",
          "source": "California Labor Code and Wage Order provisions",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "regulation",
          "label": "Consumer Credit Protection Act wage garnishment limits, 15 U.S.C. §1673; 29 CFR Part 870",
          "source": "Consumer Credit Protection Act wage garnishment limits, 15 U.S.C. §1673; 29 CFR Part 870",
          "url": "https://www.ecfr.gov/current/title-29/part-870"
        },
        {
          "kind": "statute",
          "label": "California Wage Garnishment Law, Code of Civil Procedure §706.020 et seq.",
          "source": "California Wage Garnishment Law, Code of Civil Procedure §706.020 et seq.",
          "url": "https://leginfo.legislature.ca.gov/faces/codesTOCSelected.xhtml?tocCode=CCP"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-028",
      "kind": "operational",
      "materials": [
        "garnishment or support order",
        "employee notification letter template",
        "payroll system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record when the order arrived and the deadline stated on it for beginning withholding or responding.\n\nWhy: Orders carry hard statutory deadlines; a missed one can make the practice liable for the full amount owed.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Log the order's receipt date and legal response deadline",
          "why": "Orders carry hard statutory deadlines; a missed one can make the practice liable for the full amount owed."
        },
        {
          "detail": "Check the court or agency seal, case number, and issuing authority, and confirm the named individual is a current employee of the practice.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Verify the order is authentic and applies to a current employee"
        },
        {
          "detail": "Different order types carry different withholding-percentage caps and priority order.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "support",
              "label": "Child or spousal support withholding order"
            },
            {
              "goto": "s4",
              "id": "creditor",
              "label": "Creditor wage garnishment"
            },
            {
              "goto": "s4",
              "id": "levy",
              "label": "Tax levy"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hr",
          "title": "Classify the order type"
        },
        {
          "detail": "Apply the disposable-earnings cap for the order type (support orders carry a higher allowable percentage than ordinary creditor garnishments) and compute the per-pay-period amount.\n\nWhy: Withholding above the statutory cap exposes the practice to liability to the employee; withholding less than ordered exposes it to the creditor or agency.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Calculate the withholding amount within statutory limits",
          "why": "Withholding above the statutory cap exposes the practice to liability to the employee; withholding less than ordered exposes it to the creditor or agency."
        },
        {
          "detail": "The practice owner or HR confirms the calculated amount, order priority, and effective date before payroll processes the first withholding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sign-off before the first withholding is processed.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Sign-off before the first withholding is processed"
        },
        {
          "detail": "Give the employee written notice of the order, the withholding amount, and the start date. This is required regardless of the employee's reaction and is not optional or negotiable at the practice level.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Notify the employee that the order is being processed"
        },
        {
          "detail": "Deduct the calculated amount from each applicable paycheck and remit it to the agency or creditor on the schedule the order specifies.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Process the withholding each pay period"
        },
        {
          "detail": "Keep the original order, the calculation worksheet, and proof of each remittance in a dedicated garnishment file, separate from general personnel records.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "File the order and remittance confirmations"
        },
        {
          "detail": "Withholding order processed and remittances underway",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Withholding order processed and remittances underway"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Wage garnishment or child-support withholding order received — A court or agency order to withhold from an employee's wages arrives.",
      "title": "Wage garnishment or child-support withholding order received",
      "trigger": "A court or agency order to withhold from an employee's wages arrives",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For a practice gift/tip acceptance policy — no institute policy reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a practice gift/tip acceptance policy — no institute policy reproduced"
          },
          "source": "For a practice gift/tip acceptance policy — no institute policy reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "IRS tip income reporting requirements, 26 U.S.C. §61 gross income; IRS Publication 531",
          "source": "IRS tip income reporting requirements, 26 U.S.C. §61 gross income; IRS Publication 531",
          "url": "https://www.irs.gov/publications/p531"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hrc-029",
      "kind": "operational",
      "materials": [
        "gift and tip register",
        "practice gift policy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Thank the patient graciously in the moment; do not commit to keeping or declining on the spot if the value is unclear.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "A patient offers a gift, gift card, or cash"
        },
        {
          "detail": "Classify the offer",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "modest",
              "label": "Modest token gift (baked goods, small card, low-value item)"
            },
            {
              "goto": "s8",
              "id": "significant",
              "label": "Cash, gift card, or a gift above the practice's review threshold"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "all-staff",
          "title": "Classify the offer"
        },
        {
          "detail": "Record the date, approximate value, and staff member in the gift/tip register.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Log the gift or tip"
        },
        {
          "detail": "Is this a cash tip?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "cash",
              "label": "Cash or cash-equivalent tip kept by the employee"
            },
            {
              "goto": "s6",
              "id": "not-cash",
              "label": "Non-cash gift, or declined"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a cash tip?"
        },
        {
          "detail": "Report the cash tip amount to payroll so it is included as taxable income for the employee, per IRS tip-reporting rules.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Add the tip to taxable income"
        },
        {
          "detail": "Confirm the register entry is complete and, if applicable, note the payroll tip-reporting date.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Close out the log entry"
        },
        {
          "detail": "Gift or tip logged and, if cash, reported",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Gift or tip logged and, if cash, reported"
        },
        {
          "detail": "The office manager reviews any cash, gift card, or higher-value gift before the staff member keeps it, checking there is no appearance of influence on a pending treatment decision.\n\nWhy: A valuable gift accepted near a treatment recommendation can look like — or become — undue influence, even when it isn't intended that way.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor review before the gift is kept.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor review before the gift is kept",
          "why": "A valuable gift accepted near a treatment recommendation can look like — or become — undue influence, even when it isn't intended that way."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Patient gifts and tips to team members — A patient offers cash, a gift card or a valuable gift to a hygienist or the front desk.",
      "title": "Patient gifts and tips to team members",
      "trigger": "A patient offers cash, a gift card or a valuable gift to a hygienist or the front desk",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For a provider/staff-patient professional boundaries policy — no institute or board program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a provider/staff-patient professional boundaries policy — no institute or board program reproduced"
          },
          "source": "For a provider/staff-patient professional boundaries policy — no institute or board program reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California licensure and professional-conduct standards for licensees",
          "source": "Dental Board of California licensure and professional-conduct standards for licensees",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "statute",
          "label": "California FEHA (Gov. Code §12940 et seq.) harassment-prevention framework, applied by analogy to workplace conduct arising from the contact",
          "source": "California FEHA (Gov. Code §12940 et seq.) harassment-prevention framework, applied by analogy to workplace conduct arising from the contact",
          "url": "https://calcivilrights.ca.gov/shpt/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hrc-030",
      "kind": "operational",
      "materials": [
        "professional boundaries policy",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "dentist",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The staff member tells the office manager (or the dentist, if the office manager is unavailable) what happened as soon as practical, in their own words.\n\nWhy: Immediate reporting keeps the record accurate and lets the practice respond before the situation develops further.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Report the contact immediately",
          "why": "Immediate reporting keeps the record accurate and lets the practice respond before the situation develops further."
        },
        {
          "detail": "Before the staff member replies to the patient personally, the office manager or dentist acknowledges the report and confirms the plan for how it will be handled.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Pause before any personal response.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "office-manager",
          "title": "Pause before any personal response"
        },
        {
          "detail": "Which direction is the contact coming from?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "patient-to-staff",
              "label": "Patient made the advance or contact toward a staff member"
            },
            {
              "goto": "s8",
              "id": "staff-to-patient",
              "label": "Staff member wants a personal relationship with a current patient"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Which direction is the contact coming from?"
        },
        {
          "detail": "The staff member declines politely, keeps the interaction professional, and does not withdraw from or alter the patient's clinical care because of the advance.\n\nWhy: The patient's treatment continues on its own track; declining a personal advance is never a reason to change or withhold care.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Decline professionally without disrupting care",
          "why": "The patient's treatment continues on its own track; declining a personal advance is never a reason to change or withhold care."
        },
        {
          "detail": "Log the date, who was involved, and how it was handled in the incident log, without unnecessary clinical detail about the patient.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the incident"
        },
        {
          "detail": "Pass the logged incident to the practice owner for pattern-tracking across staff and patients over time.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the practice owner"
        },
        {
          "detail": "Boundary incident handled and documented",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Boundary incident handled and documented"
        },
        {
          "detail": "The dentist and office manager assess whether the patient is in an active clinical relationship with the practice. A personal relationship must never begin during active treatment.\n\nWhy: Starting a personal relationship with a patient currently under care creates a licensure and ethics exposure that discharge or transfer resolves.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Evaluate the active-treatment conflict",
          "why": "Starting a personal relationship with a patient currently under care creates a licensure and ethics exposure that discharge or transfer resolves."
        },
        {
          "detail": "The dentist or practice owner must sign off that the clinical relationship has formally ended (discharge or transfer of care documented) before any personal contact proceeds — never during active treatment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sign-off before any personal relationship begins.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Sign-off before any personal relationship begins"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Professional boundaries: patient romantic advance, social-media friend request or personal contact — A patient asks a team member out, sends a friend request, or a staff member wants to date a patient.",
      "title": "Professional boundaries: patient romantic advance, social-media friend request or personal contact",
      "trigger": "A patient asks a team member out, sends a friend request, or a staff member wants to date a patient",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and Wage Order provisions (including Labor Code §96(k) protection for lawful off-duty conduct)",
          "source": "California Labor Code and Wage Order provisions (including Labor Code §96(k) protection for lawful off-duty conduct)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California licensure and scope-of-practice standards for licensees engaged in outside dental-adjacent work",
          "source": "Dental Board of California licensure and scope-of-practice standards for licensees engaged in outside dental-adjacent work",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "For a conflict-of-interest disclosure and mitigation process — no institute program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a conflict-of-interest disclosure and mitigation process — no institute program reproduced"
          },
          "source": "For a conflict-of-interest disclosure and mitigation process — no institute program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hrc-031",
      "kind": "operational",
      "materials": [
        "conflict-of-interest disclosure form",
        "employee handbook"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "The employee completes the conflict-of-interest disclosure form describing the outside job, business, or vendor relationship.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Employee discloses the outside activity"
        },
        {
          "detail": "Check whether the activity involves a competing practice, direct patient solicitation, a vendor relationship with purchasing influence, or a licensure/scope-of-practice question.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Assess the conflict category"
        },
        {
          "detail": "Is there a material conflict?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "none",
              "label": "No material conflict identified"
            },
            {
              "goto": "s7",
              "id": "conflict",
              "label": "Material conflict identified"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hr",
          "title": "Is there a material conflict?"
        },
        {
          "detail": "Store the disclosure form, the conflict assessment, and any mitigation plan in the personnel file.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "File the disclosure and outcome"
        },
        {
          "detail": "Set a calendar reminder for the employee to re-confirm or update the disclosure at the next annual review.\n\nWhy: Outside activities change; a one-time disclosure goes stale.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Schedule the annual re-disclosure reminder",
          "why": "Outside activities change; a one-time disclosure goes stale."
        },
        {
          "detail": "Conflict-of-interest disclosure processed",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Conflict-of-interest disclosure processed"
        },
        {
          "detail": "Options may include schedule limits to prevent overlap, a written reminder of non-solicitation expectations toward the practice's patients, or recusal from any vendor purchasing decisions.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Negotiate a mitigation plan"
        },
        {
          "detail": "The practice owner reviews and signs off on any restriction or mitigation plan before it takes effect, and before any disciplinary consequence is attached to non-compliance.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sign-off on the mitigation plan.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Sign-off on the mitigation plan"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Outside employment, side business and conflict-of-interest disclosure — An employee takes a second job at a competitor, sells products to patients, or consults for a vendor.",
      "title": "Outside employment, side business and conflict-of-interest disclosure",
      "trigger": "An employee takes a second job at a competitor, sells products to patients, or consults for a vendor",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and Wage Order provisions",
          "source": "California Labor Code and Wage Order provisions",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "National Labor Relations Act Section 7, 29 U.S.C. §157 — protects concerted activity for most private-sector, non-supervisory employees regardless of union status",
          "source": "National Labor Relations Act Section 7, 29 U.S.C. §157 — protects concerted activity for most private-sector, non-supervisory employees regardless of union status",
          "url": "https://www.nlrb.gov/about-nlrb/rights-we-protect/the-law/employees/concerted-activity"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hrc-032",
      "kind": "operational",
      "materials": [
        "NLRA Section 7 rights summary",
        "employee handbook non-retaliation clause"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note only that the awareness occurred — do not yet say or do anything toward the employees involved.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "A manager becomes aware staff are discussing pay or organizing"
        },
        {
          "detail": "Before reacting, the owner or HR confirms: discussing wages, circulating a petition, or contacting a union representative is protected concerted activity under NLRA Section 7 for most non-supervisory employees, whether or not the office is unionized. Retaliation, surveillance, or interrogation about it is illegal.\n\nWhy: This is the single highest-risk moment in the protocol — an untrained manager's instinctive reaction (asking who started it, disciplining a participant, changing schedules to separate people) is itself the violation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance check before any manager reaction.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Compliance check before any manager reaction",
          "why": "This is the single highest-risk moment in the protocol — an untrained manager's instinctive reaction (asking who started it, disciplining a participant, changing schedules to separate people) is itself the violation."
        },
        {
          "detail": "Continue normal supervision and normal business operations. Do not ask who started the discussion, do not discipline anyone for it, and do not increase monitoring of the employees involved.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Do not question, discipline, or monitor the employees involved"
        },
        {
          "detail": "Has a union representative contacted the office, or has a formal demand been received?",
          "forks": [
            {
              "goto": "s8",
              "id": "yes",
              "label": "Yes — a representative contacted the office or a written demand was received"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "no",
              "label": "No formal contact yet, just internal discussion"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Has a union representative contacted the office, or has a formal demand been received?"
        },
        {
          "detail": "No formal demand exists yet — take no special action beyond ensuring managers understand the compliance boundary above.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Continue normal operations"
        },
        {
          "detail": "Record only the date and who was notified (owner/counsel). Never log the content of a wage discussion in a punitive or evaluative tone.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Log the incident factually"
        },
        {
          "detail": "Protected-activity situation handled without retaliation",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Protected-activity situation handled without retaliation"
        },
        {
          "detail": "Direct every future contact from the representative to the practice owner or its counsel. Do not respond informally, and do not unilaterally change wages, benefits, or schedules while the matter is active.\n\nWhy: Ad hoc changes to pay or conditions during this window can be read as either a threat or an inducement, both of which are separately unlawful.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Route all communication to the owner and legal counsel",
          "why": "Ad hoc changes to pay or conditions during this window can be read as either a threat or an inducement, both of which are separately unlawful."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Employees discuss wages or begin organizing: protected-activity response — Staff compare pay openly, circulate a petition, or a union representative contacts the office.",
      "title": "Employees discuss wages or begin organizing: protected-activity response",
      "trigger": "Staff compare pay openly, circulate a petition, or a union representative contacts the office",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California FEHA (Gov. Code §12940 et seq.), CFRA, SB 1343 harassment prevention training (Gov. Code §12950.1); SB 553 Workplace Violence Prevention (Labor Code §6401.9)",
          "source": "California FEHA (Gov. Code §12940 et seq.), CFRA, SB 1343 harassment prevention training (Gov. Code §12950.1); SB 553 Workplace Violence Prevention (Labor Code §6401.9)",
          "url": "https://calcivilrights.ca.gov/shpt/"
        },
        {
          "kind": "generic",
          "label": "For an off-duty team-event liability checklist (venue, alcohol service, transportation, opt-in) — no institute or insurer program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for an off-duty team-event liability checklist (venue, alcohol service, transportation, opt-in) — no institute or insurer program reproduced"
          },
          "source": "For an off-duty team-event liability checklist (venue, alcohol service, transportation, opt-in) — no institute or insurer program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "hrc-033",
      "kind": "operational",
      "materials": [
        "event planning checklist",
        "harassment prevention policy handout",
        "workers' compensation coverage summary",
        "sign-in sheet or e-vite with policy reminder"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Office manager reviews the planned event against the practice's off-duty event checklist before booking anything.\n\nWhy: Off-duty conduct at a practice-sponsored event can still create employer liability for harassment, injury, and workers' compensation exposure — the risk profile of the event drives which controls are needed.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "yes-risk",
              "label": "Alcohol will be served or the activity is physical (sports, ropes course, etc.)"
            },
            {
              "goto": "s10",
              "id": "no-risk",
              "label": "Low-risk event (meal, office party with no alcohol, seated activity)"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Will alcohol be served or is the activity physically vigorous?",
          "why": "Off-duty conduct at a practice-sponsored event can still create employer liability for harassment, injury, and workers' compensation exposure — the risk profile of the event drives which controls are needed."
        },
        {
          "detail": "Office manager brings the venue, guest list, alcohol plan, and activity description to the practice owner for sign-off before any booking or deposit.\n\nWhy: Higher-risk events warrant owner awareness given the increased liability exposure.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify practice owner and review the event plan together",
          "why": "Higher-risk events warrant owner awareness given the increased liability exposure."
        },
        {
          "detail": "Practice owner or office manager approves the specific controls before booking: host-poured drink tickets (not open bar), a defined cutoff time, non-alcoholic options prominently offered, and — for physical activities — a waiver/release and confirmation the venue carries its own liability coverage.\n\nWhy: A named sign-off before money is spent keeps the decision auditable and keeps an unreviewed open bar or unwaived physical activity from happening by default.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor sign-off on event plan and controls.",
            "role": "practice-owner or office-manager",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Supervisor sign-off on event plan and controls",
          "why": "A named sign-off before money is spent keeps the decision auditable and keeps an unreviewed open bar or unwaived physical activity from happening by default."
        },
        {
          "detail": "If alcohol is served, the practice pre-arranges or reimburses rideshare/taxi so no one who has been drinking is expected to drive, and communicates this in the invite.\n\nWhy: Reduces both the human and the liability risk of impaired driving after a sponsored event.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange or subsidize transportation options",
          "why": "Reduces both the human and the liability risk of impaired driving after a sponsored event."
        },
        {
          "detail": "Attendance is not mandatory and is not scheduled to conflict with religious observance or caregiving obligations; non-drinkers have a clear, unremarked-upon non-alcoholic option; the event is accessible to staff with disabilities.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm event is voluntary and inclusive"
        },
        {
          "detail": "A brief, friendly reminder (verbal or posted) that the harassment-prevention and conduct policy applies, and who to contact if something happens.\n\nWhy: A visible reminder at the point of risk is more effective than a policy read weeks earlier.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Restate conduct expectations at the start of the event",
          "why": "A visible reminder at the point of risk is more effective than a policy read weeks earlier."
        },
        {
          "detail": "Office manager checks in the following business day.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "incident-none",
              "label": "No incidents reported"
            },
            {
              "goto": "s11",
              "id": "incident-reported",
              "label": "An incident (harassment, injury, impairment) was reported"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did anything happen during or after the event that needs follow-up?"
        },
        {
          "detail": "Record event date, controls used (transportation, drink-ticket policy, waiver), attendance, and any incident reference number in the HR event log.\n\nRecord: event log entry with controls applied and any linked incident record",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the event and outcome"
        },
        {
          "detail": "Event closed out",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Event closed out"
        },
        {
          "detail": "Send the invite with a one-line reminder that the conduct policy and harassment-prevention policy apply at all practice-sponsored events, then proceed to scheduling.\n\nWhy: Even low-risk events are still work events for policy purposes.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Send standard event reminder with policy note",
          "why": "Even low-risk events are still work events for policy purposes."
        },
        {
          "detail": "Hand off to the harassment/workplace-violence investigation protocol or the workers' compensation injury-reporting protocol depending on what occurred; HR opens the matter formally rather than handling it informally because it happened 'off the clock.'\n\nWhy: A practice-sponsored event is a work event for policy and workers' compensation purposes regardless of the venue or time of day.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Route to the applicable incident protocol",
          "why": "A practice-sponsored event is a work event for policy and workers' compensation purposes regardless of the venue or time of day."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Team event with alcohol or physical activity (liability, harassment, comp coverage) — The practice plans a holiday party, offsite or team-building activity.",
      "title": "Team event with alcohol or physical activity (liability, harassment, comp coverage)",
      "trigger": "The practice plans a holiday party, offsite or team-building activity",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "988 Suicide & Crisis Lifeline (SAMHSA/HHS national hotline)",
          "source": "988 Suicide & Crisis Lifeline (SAMHSA/HHS national hotline)",
          "url": "https://988lifeline.org/"
        },
        {
          "kind": "statute",
          "label": "California FEHA (Gov. Code §12940 et seq.) — disability accommodation obligations, including for mental health conditions",
          "source": "California FEHA (Gov. Code §12940 et seq.) — disability accommodation obligations, including for mental health conditions",
          "url": "https://calcivilrights.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "For a workplace acute-distress response sequence (safety first, privacy, warm handoff, no diagnosis by non-clinicians) — no vendor EAP program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a workplace acute-distress response sequence (safety first, privacy, warm handoff, no diagnosis by non-clinicians) — no vendor EAP program reproduced"
          },
          "source": "For a workplace acute-distress response sequence (safety first, privacy, warm handoff, no diagnosis by non-clinicians) — no vendor EAP program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "hrc-034",
      "kind": "operational",
      "materials": [
        "988 Suicide & Crisis Lifeline card",
        "employee assistance program contact card if available",
        "private room",
        "shift-coverage list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the team member states an intent and a means to harm themselves right now, or appears in immediate physical danger, call 911 immediately; for a mental health crisis without immediate physical danger, call or text 988 (Suicide & Crisis Lifeline) together with the person, or call 911 if they are unwilling to wait. Do not leave the person alone.\n\nWhy: Life safety takes priority over any HR, privacy, or scheduling process — this is a non-negotiable rule-based gate before anything else happens.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Immediate danger check — call 911 or 988 first if life is at risk.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Immediate danger check — call 911 or 988 first if life is at risk",
          "why": "Life safety takes priority over any HR, privacy, or scheduling process — this is a non-negotiable rule-based gate before anything else happens."
        },
        {
          "detail": "Assess based on what was said and observed — do not attempt to diagnose or evaluate risk clinically.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "danger-yes",
              "label": "Yes — imminent danger"
            },
            {
              "goto": "s7",
              "id": "danger-no",
              "label": "No — distressed but not in immediate danger"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the person in immediate physical danger right now?"
        },
        {
          "detail": "One person calls 911 and stays on the line; another quietly moves other staff and any patients away from the area without drawing attention to the individual.\n\nWhy: Staying with the person prevents isolation during the highest-risk window; clearing the area protects the person's dignity and privacy.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Call 911, stay with the person, clear the area",
          "why": "Staying with the person prevents isolation during the highest-risk window; clearing the area protects the person's dignity and privacy."
        },
        {
          "detail": "Office manager notifies the practice owner and HR by phone as soon as it is safe to step away, giving only what is needed to coordinate coverage and support.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify practice owner and HR"
        },
        {
          "detail": "Record date, time, who responded, what resources were offered (988/911), and the follow-up plan in a confidential personnel record separate from clinical/patient files — factual and non-diagnostic language only.\n\nRecord: confidential personnel-file incident note with response timeline and follow-up plan",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Document the incident confidentially in personnel file"
        },
        {
          "detail": "Immediate response complete; follow-up scheduled",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Immediate response complete; follow-up scheduled"
        },
        {
          "detail": "Bring the team member to a private room away from patients and coworkers; a colleague stays with them the whole time rather than leaving them alone.\n\nWhy: Privacy protects the employee's dignity and reduces the chance of the moment being observed or discussed by patients.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Move to a private space and stay with them",
          "why": "Privacy protects the employee's dignity and reduces the chance of the moment being observed or discussed by patients."
        },
        {
          "detail": "Ask directly and calmly whether they are thinking about suicide or self-harm; if yes, offer to call or text 988 together right now, and support them in doing so rather than leaving them to do it alone.\n\nWhy: Asking directly does not increase risk and signals the practice is taking it seriously; doing it together removes a barrier to reaching out.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Offer to call or text 988 together",
          "why": "Asking directly does not increase risk and signals the practice is taking it seriously; doing it together removes a barrier to reaching out."
        },
        {
          "detail": "Reassign the team member's remaining patients/tasks for the day, and arrange for them not to drive themselves home alone if they are visibly distressed — call a trusted contact or arrange a ride.\n\nWhy: Removes the operational pressure to 'push through' the shift and reduces risk during the commute.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange shift coverage and safe transport home",
          "why": "Removes the operational pressure to 'push through' the shift and reduces risk during the commute."
        },
        {
          "detail": "Practice owner or HR schedules a private, supportive check-in for the next business day and reminds the employee of any available EAP or crisis resources; this is a wellbeing check, not a disciplinary meeting.\n\nWhy: A named, scheduled follow-up prevents a serious event from being handled once and then never revisited.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor-scheduled follow-up before return to normal duties.",
            "role": "practice-owner or HR",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "hr",
          "title": "Supervisor-scheduled follow-up before return to normal duties",
          "why": "A named, scheduled follow-up prevents a serious event from being handled once and then never revisited."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Team member in acute distress or expresses self-harm — A coworker says they want to hurt themselves or breaks down during a shift.",
      "title": "Team member in acute distress or expresses self-harm",
      "trigger": "A coworker says they want to hurt themselves or breaks down during a shift",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California licensure verification and diversion/impairment reporting for auxiliaries and licensees",
          "source": "Dental Board of California licensure verification and diversion/impairment reporting for auxiliaries and licensees",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "For a controlled-substance/agent diversion response (secure supply, remove from patient care, document, report to licensing board) — no vendor or institute impairment program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a controlled-substance/agent diversion response (secure supply, remove from patient care, document, report to licensing board) — no vendor or institute impairment program reproduced"
          },
          "source": "For a controlled-substance/agent diversion response (secure supply, remove from patient care, document, report to licensing board) — no vendor or institute impairment program reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "hrc-035",
      "kind": "operational",
      "materials": [
        "nitrous oxide usage log",
        "tank inventory sheet",
        "Dental Board of California licensure lookup",
        "state licensing board diversion-reporting contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If a team member currently appears euphoric, disoriented, or otherwise impaired, immediately remove them from any patient-facing role and from operating equipment; call 911 if they show signs of medical distress (unresponsiveness, difficulty breathing).\n\nWhy: An impaired person operating clinical equipment or dispensing agents is an immediate patient-safety and staff-safety risk that overrides any investigative process.",
          "gate": {
            "ack": "I confirm I have completed this step as written: If the person is actively impaired now, remove them from all clinical duty and patient contact immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "If the person is actively impaired now, remove them from all clinical duty and patient contact immediately",
          "why": "An impaired person operating clinical equipment or dispensing agents is an immediate patient-safety and staff-safety risk that overrides any investigative process."
        },
        {
          "detail": "Lock or restrict access to the nitrous oxide tanks and delivery equipment immediately, and note current tank levels against the log.\n\nWhy: Preserves evidence of the discrepancy and prevents further access while the situation is unclear.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Secure the nitrous supply and tank room",
          "why": "Preserves evidence of the discrepancy and prevents further access while the situation is unclear."
        },
        {
          "detail": "Compare nitrous usage entries against scheduled cases for the period in question: date/time of use, patient case linked to each entry, tank weight or gauge readings before and after.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Reconcile usage log against case records"
        },
        {
          "detail": "Practice owner and dentist review the reconciled log together.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "confirmed",
              "label": "Yes — usage is unexplained by case logs, or tank tampering is evident"
            },
            {
              "goto": "s11",
              "id": "explained",
              "label": "No — a documentation gap or equipment issue explains it"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the reconciliation confirm unexplained use?"
        },
        {
          "detail": "The treating/supervising dentist and practice owner jointly review the evidence before any confrontation or report — this protects against acting on an incomplete picture while still moving promptly given the safety stakes.\n\nWhy: A misuse or diversion allegation can end a career and threaten a license; it needs licensed clinical judgment involved before the practice acts, not after.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed dentist and practice owner sign off before confronting the employee or reporting.",
            "role": "supervising dentist and practice owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed dentist and practice owner sign off before confronting the employee or reporting",
          "why": "A misuse or diversion allegation can end a career and threaten a license; it needs licensed clinical judgment involved before the practice acts, not after."
        },
        {
          "detail": "Practice owner and, where applicable, HR meet privately with the employee, present the findings factually, and give them the opportunity to respond before any decision is finalized.\n\nWhy: Due process before action reduces legal exposure and is fair to the employee if there is an innocent explanation.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hold a confidential meeting with the employee",
          "why": "Due process before action reduces legal exposure and is fair to the employee if there is an innocent explanation."
        },
        {
          "detail": "Based on the severity of evidence and the employee's response.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "leave",
              "label": "Administrative leave pending investigation"
            },
            {
              "goto": "s8",
              "id": "non-clinical",
              "label": "Temporary reassignment to non-clinical, non-controlled-agent duties"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Placed on leave pending investigation, or return to non-clinical duty?"
        },
        {
          "detail": "Check the employee's current status with the Dental Board of California (or applicable auxiliary licensing body) and report suspected diversion or impairment consistent with the practice's mandatory reporting obligations under its license.\n\nWhy: Licensing boards have their own diversion-reporting requirements distinct from internal HR process; verifying status also confirms whether the person can lawfully continue in any clinical role.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Verify licensure status and report where required",
          "why": "Licensing boards have their own diversion-reporting requirements distinct from internal HR process; verifying status also confirms whether the person can lawfully continue in any clinical role."
        },
        {
          "detail": "Record the timeline, evidence reviewed, licensed sign-off, employee response, decision, and any board report reference number in a confidential personnel file.\n\nRecord: confidential investigation file with evidence, sign-off, decision and any regulatory report reference",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Document investigation, decision and report in confidential file"
        },
        {
          "detail": "Investigation and reporting steps complete",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Investigation and reporting steps complete"
        },
        {
          "detail": "Record what explained the discrepancy (e.g., a logging error, equipment recalibration) and any process fix (log training, gauge check).\n\nRecord: investigation note documenting the benign explanation and corrective action",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the finding and close"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Nitrous oxide misuse or tank tampering by a team member suspected — Nitrous consumption exceeds case logs, a tank is found open after hours, or a staff member appears euphoric.",
      "title": "Nitrous oxide misuse or tank tampering by a team member suspected",
      "trigger": "Nitrous consumption exceeds case logs, a tank is found open after hours, or a staff member appears euphoric",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §2802 — employer reimbursement of necessary business expenses, including required use of a personal vehicle",
          "source": "California Labor Code §2802 — employer reimbursement of necessary business expenses, including required use of a personal vehicle",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "public_domain",
          "label": "IRS standard mileage rate for business use of a personal vehicle (published annually)",
          "source": "IRS standard mileage rate for business use of a personal vehicle (published annually)",
          "url": "https://www.irs.gov/tax-professionals/standard-mileage-rates"
        },
        {
          "kind": "statute",
          "label": "California workers' compensation coverage extends to injuries sustained while performing work duties, including authorized off-site errands (Labor Code §3600 et seq.)",
          "source": "California workers' compensation coverage extends to injuries sustained while performing work duties, including authorized off-site errands (Labor Code §3600 et seq.)",
          "url": "https://www.dir.ca.gov/dwc/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hrc-036",
      "kind": "operational",
      "materials": [
        "mileage log form or app",
        "proof-of-insurance record on file",
        "IRS standard mileage rate reference",
        "errand authorization checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the employee holds a valid driver's license, has proof of personal auto insurance on file with the office, and has voluntarily agreed to use their vehicle — driving is never made a condition of employment without consent.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the employee is eligible and willing to drive for the errand"
        },
        {
          "detail": "Office manager confirms before dispatching the errand.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "eligible-yes",
              "label": "Yes — license valid, insurance on file, willing"
            },
            {
              "goto": "s9",
              "id": "eligible-no",
              "label": "No — missing insurance on file, or unwilling"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the employee eligible and willing?"
        },
        {
          "detail": "Note the purpose, destination, and expected duration before the employee leaves; give them the mileage log form or app link.\n\nWhy: Having the authorization recorded before departure supports both mileage reimbursement and any later workers' compensation determination that the trip was within the course of employment.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Authorize the errand and record start details",
          "why": "Having the authorization recorded before departure supports both mileage reimbursement and any later workers' compensation determination that the trip was within the course of employment."
        },
        {
          "detail": "Employee records odometer start/end (or app-tracked distance), route, and reports immediately if any accident, traffic stop, or vehicle issue occurs during the errand.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Employee logs mileage and any incident"
        },
        {
          "detail": "Office manager checks in on return.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "incident-no",
              "label": "No — errand completed without incident"
            },
            {
              "goto": "s10",
              "id": "incident-yes",
              "label": "Yes — accident, injury, or citation occurred"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did an accident or injury occur during the errand?"
        },
        {
          "detail": "Office manager reviews the logged mileage against the practice's reimbursement rate (at or above the applicable standard) and includes it in the next payroll or expense reimbursement cycle.\n\nWhy: California law requires timely reimbursement of necessary business expenses incurred using a personal vehicle for work.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Process mileage reimbursement",
          "why": "California law requires timely reimbursement of necessary business expenses incurred using a personal vehicle for work."
        },
        {
          "detail": "File the completed mileage log in the reimbursement records; if an incident occurred, cross-reference the workers' compensation claim number.\n\nRecord: mileage log with reimbursement status and any linked claim reference",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "File the mileage log and any incident reference"
        },
        {
          "detail": "Errand closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Errand closed out"
        },
        {
          "detail": "Use a paid courier/delivery service, ask another eligible and willing team member, or have the office manager or owner run the errand instead.\n\nWhy: The practice cannot require an ineligible or unwilling employee to use their personal vehicle for work.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange an alternative (courier, another staff member, owner)",
          "why": "The practice cannot require an ineligible or unwilling employee to use their personal vehicle for work."
        },
        {
          "detail": "Office manager notifies HR/practice owner immediately and routes the case to the workers' compensation claim-form protocol (California §5401 — claim form provided within one working day of knowledge of injury).\n\nWhy: An injury during an authorized work errand is treated as a workplace injury even though it happened off the practice's physical premises.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Hand off to workers' compensation injury-reporting protocol",
          "why": "An injury during an authorized work errand is treated as a workplace injury even though it happened off the practice's physical premises."
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Employee errands off-site (bank runs, lab drops): driving policy, mileage and injury coverage — A team member is sent to the bank, a lab or a supply pickup in a personal vehicle.",
      "title": "Employee errands off-site (bank runs, lab drops): driving policy, mileage and injury coverage",
      "trigger": "A team member is sent to the bank, a lab or a supply pickup in a personal vehicle",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California continuing education requirements (accepting sponsored CE does not exempt a licensee from independent CE record-keeping obligations)",
          "source": "Dental Board of California continuing education requirements (accepting sponsored CE does not exempt a licensee from independent CE record-keeping obligations)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "For a vendor gift/meal/CE disclosure and threshold policy (log, cap, sign-off above threshold) — no institute or vendor compliance program reproduced; dental practices are not themselves subject to the federal Physician Open Payments program, which applies to physicians and teaching hospitals, but the disclosure discipline is the same generic control — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a vendor gift/meal/CE disclosure and threshold policy (log, cap, sign-off above threshold) — no institute or vendor compliance program reproduced; dental practices are not themselves subject to the federal Physician Open Payments program, which applies to physicians and teaching hospitals, but the disclosure discipline is the same generic control"
          },
          "source": "For a vendor gift/meal/CE disclosure and threshold policy (log, cap, sign-off above threshold) — no institute or vendor compliance program reproduced; dental practices are not themselves subject to the federal Physician Open Payments program, which applies to physicians and teaching hospitals, but the disclosure discipline is the same generic control — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hrc-037",
      "kind": "operational",
      "materials": [
        "vendor gift/meal disclosure log",
        "practice conflict-of-interest policy",
        "CE credit tracking sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "compliance-officer",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Whoever receives the offer (dentist, owner, or staff member) records the vendor name, what is offered (meal, gift, trip, sponsored CE), and its approximate value in the disclosure log before responding.\n\nWhy: Logging at the point of offer, not after acceptance, keeps the record complete even for offers that are later declined.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Log the vendor offer when it is made",
          "why": "Logging at the point of offer, not after acceptance, keeps the record complete even for offers that are later declined."
        },
        {
          "detail": "Compare the offer's value and type against the practice's written conflict-of-interest policy thresholds.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "over-threshold",
              "label": "Yes — exceeds threshold (travel, high-value gift, non-working meal)"
            },
            {
              "goto": "s10",
              "id": "under-threshold",
              "label": "No — modest working meal or low-value item within pre-approved policy"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the offer exceed the practice's pre-approved threshold (e.g., a modest working meal)?"
        },
        {
          "detail": "The compliance officer reviews the offer against the conflict-of-interest policy and either approves, approves with conditions (e.g., the whole team attends rather than one clinician alone), or declines, before the offer is accepted.\n\nWhy: Above-threshold offers carry more reputational and judgment-influence risk and need a named review before commitment, not a retroactive log entry.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews and signs off before acceptance.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews and signs off before acceptance",
          "why": "Above-threshold offers carry more reputational and judgment-influence risk and need a named review before commitment, not a retroactive log entry."
        },
        {
          "detail": "Was the offer approved?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "approved",
              "label": "Approved (with or without conditions)"
            },
            {
              "goto": "s11",
              "id": "declined",
              "label": "Declined"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Was the offer approved?"
        },
        {
          "detail": "Does the offer include sponsored continuing education (CE) credit?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "ce-yes",
              "label": "Yes — sponsored CE course or event"
            },
            {
              "goto": "s7",
              "id": "ce-no",
              "label": "No CE component"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the offer include sponsored continuing education (CE) credit?"
        },
        {
          "detail": "Confirm the course is accredited toward the licensee's continuing education requirement and record the credit hours in the practice's CE tracking sheet, independent of the vendor's own records.\n\nWhy: Accepting sponsored CE does not relieve the licensee of the personal obligation to maintain accurate, independently verifiable CE records for license renewal.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Independently verify and track CE credit",
          "why": "Accepting sponsored CE does not relieve the licensee of the personal obligation to maintain accurate, independently verifiable CE records for license renewal."
        },
        {
          "detail": "Complete the log entry with vendor, offer type, value, decision, sign-off (if applicable), and any linked CE credit record.\n\nRecord: vendor gift/meal/CE disclosure log with decision and sign-off trail",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Finalize the disclosure log entry"
        },
        {
          "detail": "The log accumulates entries until the practice's scheduled annual conflict-of-interest policy review, when the compliance officer reviews the full year's pattern of offers and acceptances.",
          "id": "s8",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 31536000,
          "title": "Hold for annual disclosure log review"
        },
        {
          "detail": "Offer handled and logged",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Offer handled and logged"
        },
        {
          "detail": "Confirm the logged entry is complete; no further sign-off needed for pre-approved, modest offers.",
          "id": "s10",
          "kind": "step",
          "role": "all-staff",
          "title": "Accept within policy and confirm the log entry"
        },
        {
          "detail": "A brief, professional message to the vendor declining the offer, without disparaging the vendor relationship.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the vendor of the decline"
        }
      ],
      "subclass": "employment-compliance-and-staff-incidents",
      "summary": "Vendor gifts, meals, sponsored CE and Open Payments transparency — A manufacturer or distributor offers a meal, trip, gift or paid CE to the dentist or team.",
      "title": "Vendor gifts, meals, sponsored CE and Open Payments transparency",
      "trigger": "A manufacturer or distributor offers a meal, trip, gift or paid CE to the dentist or team",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §432.3 (pay-scale disclosure in job postings)",
          "source": "California Labor Code §432.3 (pay-scale disclosure in job postings)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "Gov. Code §12952 (Fair Chance Act — no criminal-history inquiry before conditional offer)",
          "source": "Gov. Code §12952 (Fair Chance Act — no criminal-history inquiry before conditional offer)"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20160,
      "frequency": "as-needed",
      "id": "hro-001",
      "kind": "operational",
      "materials": [
        "job description template",
        "pay-scale worksheet",
        "applicant tracking sheet",
        "interview scorecard",
        "posting sites list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "hr",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Get written sign-off from the practice owner on the role, hours, and the pay-scale band before drafting a posting.\n\nWhy: California Labor Code §432.3 requires the pay scale to be disclosed on the posting itself, so it must be settled before anything is published.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Confirm vacancy and pay-scale band with the owner",
          "why": "California Labor Code §432.3 requires the pay scale to be disclosed on the posting itself, so it must be settled before anything is published."
        },
        {
          "detail": "Write duties, required licenses/certifications, schedule, and include the numeric pay-scale range in the posting text.\n\nWhy: A posting missing the pay range is non-compliant in California and several other states.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Draft the job posting including the pay-scale range",
          "why": "A posting missing the pay range is non-compliant in California and several other states."
        },
        {
          "detail": "Post to the practice's careers page and selected job boards; log the posting date and channels used.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Publish the posting to approved channels"
        },
        {
          "detail": "Review each resume against required licenses, experience, and availability; log a pass/hold/reject decision for every applicant.\n\nWhy: A documented, consistent screening standard reduces disparate-impact risk.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Screen incoming applications against the scorecard",
          "why": "A documented, consistent screening standard reduces disparate-impact risk."
        },
        {
          "detail": "Route qualified candidates to interview",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "phone-screen",
              "label": "15-minute phone screen first, then in-person interview"
            },
            {
              "goto": "s7",
              "id": "direct-interview",
              "label": "Schedule in-person interview directly"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Route qualified candidates to interview"
        },
        {
          "detail": "Confirm licensure status, availability, and salary expectations by phone before committing interview time.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Run a brief phone screen"
        },
        {
          "detail": "Use the same scorecard questions for every candidate for the role; include the hiring manager and, for clinical roles, a clinical staff member on the panel.\n\nWhy: Structured, identical questions across candidates is the standard defense against discrimination claims.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Conduct structured in-person interview(s)",
          "why": "Structured, identical questions across candidates is the standard defense against discrimination claims."
        },
        {
          "detail": "Verify the interview and any application form did not ask about criminal history; that inquiry is deferred until after a conditional offer under the Fair Chance Act.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm no criminal-history inquiry before conditional offer.",
            "role": "hr",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "hr",
          "title": "Confirm no criminal-history inquiry before conditional offer"
        },
        {
          "detail": "Document why the finalist was selected over other qualified candidates, referencing scorecard results.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Select finalist and record decision rationale"
        },
        {
          "detail": "Pass finalist name, role, and start-date target to hro-002 (license/exclusion verification) and hro-004 (offer paperwork).",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "Hand off finalist to conditional-offer and verification track"
        },
        {
          "detail": "Log final applicant disposition (hired/declined/withdrawn) for every candidate.\n\nRecord: Log final applicant disposition (hired/declined/withdrawn) for every candidate in the tracking sheet, retained per records policy.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Close out the posting record"
        },
        {
          "detail": "Posting and interview loop complete",
          "id": "s12",
          "kind": "step",
          "title": "Posting and interview loop complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Job posting with pay-scale disclosure, candidate screening and interview loop — A vacancy is approved by the owner.",
      "title": "Job posting with pay-scale disclosure, candidate screening and interview loop",
      "trigger": "A vacancy is approved by the owner",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HHS-OIG exclusion screening 42 CFR §1001.1901",
          "source": "HHS-OIG exclusion screening 42 CFR §1001.1901",
          "url": "https://oig.hhs.gov/exclusions/"
        },
        {
          "kind": "regulation",
          "label": "Radiography certification requirements (Dental Board of California 16 CCR §1014.1, B&P §1656); CPR/BLS current certification per practice policy, not independently board-mandated for every role",
          "source": "Radiography certification requirements (Dental Board of California 16 CCR §1014.1, B&P §1656); CPR/BLS current certification per practice policy, not independently board-mandated for every role"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "hro-002",
      "kind": "operational",
      "materials": [
        "state licensing board lookup",
        "OIG/GSA exclusion list lookup",
        "reference-check script",
        "verification checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Verify the candidate has received and accepted a conditional written offer before beginning verification steps.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Confirm a conditional offer has been extended"
        },
        {
          "detail": "Obtain copies of state license, DEA/permit numbers if applicable, CPR/BLS card, and radiography certification as required for the role.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Collect credential documents from the candidate"
        },
        {
          "detail": "Look up the candidate's license number on the state dental board's public license-lookup site; confirm status is active and unrestricted.\n\nWhy: A candidate-provided license copy can be expired or altered; the board's own record is authoritative.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Verify license status directly with the state licensing board",
          "why": "A candidate-provided license copy can be expired or altered; the board's own record is authoritative."
        },
        {
          "detail": "Search the candidate's name and NPI (if applicable) against the HHS-OIG List of Excluded Individuals/Entities and the GSA System for Award Management exclusion list.\n\nWhy: Employing an excluded individual in a role touching federal health-program billing risks the practice's own program participation.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Run the OIG and GSA exclusion-list checks",
          "why": "Employing an excluded individual in a role touching federal health-program billing risks the practice's own program participation."
        },
        {
          "detail": "Evaluate exclusion-check result",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "clear",
              "label": "No exclusion match found — proceed"
            },
            {
              "goto": "s10",
              "id": "hit",
              "label": "Possible exclusion match found"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Evaluate exclusion-check result"
        },
        {
          "detail": "Contact at least two prior employers or supervisors; document dates of employment and reason for leaving where the reference provides it.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Complete professional reference checks"
        },
        {
          "detail": "Enter license number, verification date, and each credential's expiry date.\n\nRecord: Enter license number, verification date, and each credential's expiry date into the credential tracker feeding hro-008.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Log all verified credentials and their expiry dates"
        },
        {
          "detail": "Notify office-manager the candidate is cleared to proceed to hro-003 (background check) and hro-004 (offer paperwork).",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Hand off cleared candidate to offer-paperwork track"
        },
        {
          "detail": "License and exclusion verification complete",
          "id": "s9",
          "kind": "step",
          "title": "License and exclusion verification complete"
        },
        {
          "detail": "Do not proceed with onboarding until the practice owner and, where warranted, counsel confirm whether the match is a false positive or a real exclusion.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate exclusion-list match to the practice owner before proceeding.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "hr",
          "title": "Escalate exclusion-list match to the practice owner before proceeding"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "License, certification, reference and exclusion-list verification — The offer stage for any clinical or billing role.",
      "title": "License, certification, reference and exclusion-list verification",
      "trigger": "The offer stage for any clinical or billing role",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Fair Credit Reporting Act, 15 U.S.C. §1681 et seq.",
          "source": "Fair Credit Reporting Act, 15 U.S.C. §1681 et seq.",
          "url": "https://www.ftc.gov/legal-library/browse/statutes/fair-credit-reporting-act"
        },
        {
          "kind": "statute",
          "label": "Gov. Code §12952 (California Fair Chance Act — timing of criminal-history inquiry)",
          "source": "Gov. Code §12952 (California Fair Chance Act — timing of criminal-history inquiry)"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 10080,
      "frequency": "as-needed",
      "id": "hro-003",
      "kind": "operational",
      "materials": [
        "FCRA disclosure form",
        "authorization form",
        "adverse-action pre-notice letter template",
        "summary of rights under FCRA"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Determine whether the role requires a background check",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "requires",
              "label": "Role has financial or patient access — background check required"
            },
            {
              "goto": "s10",
              "id": "not-required",
              "label": "Role does not require a background check"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "title": "Determine whether the role requires a background check"
        },
        {
          "detail": "Give the candidate a document that consists solely of the disclosure that a consumer report may be obtained for employment purposes — no other content on the page.\n\nWhy: FCRA §604(b)(2) requires the disclosure to be in a document that consists solely of the disclosure.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Provide a clear, standalone FCRA disclosure",
          "why": "FCRA §604(b)(2) requires the disclosure to be in a document that consists solely of the disclosure."
        },
        {
          "detail": "Do not submit the order to the consumer reporting agency until the candidate has signed the authorization form.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain signed written authorization before ordering the report.",
            "role": "hr",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "hr",
          "title": "Obtain signed written authorization before ordering the report"
        },
        {
          "detail": "Submit the candidate's authorized information to the consumer reporting agency and log the order date.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Order the consumer report from the reporting agency"
        },
        {
          "detail": "Assess any findings against a written individualized-assessment standard (nature of offense, time elapsed, job relevance) rather than a blanket exclusion.\n\nWhy: An automatic disqualification policy risks disparate-impact liability; an individualized assessment is the defensible standard.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the report against role-relevant, individualized criteria",
          "why": "An automatic disqualification policy risks disparate-impact liability; an individualized assessment is the defensible standard."
        },
        {
          "detail": "Decide whether the report supports proceeding",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "clear-proceed",
              "label": "No disqualifying findings — proceed with hire"
            },
            {
              "goto": "s11",
              "id": "adverse-considered",
              "label": "Findings may support withdrawing the offer"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "title": "Decide whether the report supports proceeding"
        },
        {
          "detail": "Log the report result and clearance decision in the hiring file.\n\nRecord: Log the report result and clearance decision in the hiring file.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Document the clear result"
        },
        {
          "detail": "Notify hr the candidate is cleared to proceed to hro-004 (offer letter and paperwork).",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Hand off to offer paperwork"
        },
        {
          "detail": "Background check process complete, candidate cleared",
          "id": "s9",
          "kind": "step",
          "title": "Background check process complete, candidate cleared"
        },
        {
          "detail": "No background check required for this role",
          "id": "s10",
          "kind": "step",
          "title": "No background check required for this role"
        },
        {
          "detail": "Provide the candidate a copy of the report and a summary of FCRA rights, and hold the decision open for a reasonable waiting period before finalizing.\n\nWhy: FCRA requires a pre-adverse notice and waiting period before the employer may act on the report.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Send the pre-adverse-action notice",
          "why": "FCRA requires a pre-adverse notice and waiting period before the employer may act on the report."
        },
        {
          "detail": "After the waiting period, send the final adverse-action notice naming the reporting agency and the candidate's right to dispute, if the offer is withdrawn.",
          "id": "s12",
          "kind": "step",
          "role": "hr",
          "title": "Issue the final adverse-action notice if the offer is withdrawn"
        },
        {
          "detail": "Log disclosure date, authorization date, pre-adverse notice date, and final decision.\n\nRecord: Log disclosure date, authorization date, pre-adverse notice date, and final decision in the hiring file.",
          "id": "s13",
          "kind": "step",
          "role": "hr",
          "title": "Document the adverse-action decision"
        },
        {
          "detail": "Adverse-action process complete, offer withdrawn",
          "id": "s14",
          "kind": "step",
          "title": "Adverse-action process complete, offer withdrawn"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Background check where permitted — FCRA disclosure, authorization and adverse-action steps — A conditional offer is extended for a role with financial or patient access.",
      "title": "Background check where permitted — FCRA disclosure, authorization and adverse-action steps",
      "trigger": "A conditional offer is extended for a role with financial or patient access",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "USCIS Form I-9, 8 CFR §274a.2 (employment eligibility verification within three business days of start)",
          "source": "USCIS Form I-9, 8 CFR §274a.2 (employment eligibility verification within three business days of start)",
          "url": "https://www.ecfr.gov/current/title-8/section-274a.2"
        },
        {
          "kind": "statute",
          "label": "California Labor Code §2810.5 (wage notice to employee)",
          "source": "California Labor Code §2810.5 (wage notice to employee)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "hro-004",
      "kind": "operational",
      "materials": [
        "offer letter template",
        "USCIS Form I-9",
        "IRS Form W-4",
        "wage-notice template",
        "new-hire reporting portal",
        "confidentiality and arbitration agreement templates"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Send a written offer stating title, pay-scale rate, schedule, and start date; obtain the candidate's signed acceptance.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Issue the written offer letter"
        },
        {
          "detail": "Lock the start date in writing and share it with office-manager for day-one scheduling (hro-005).",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Confirm the start date with the candidate"
        },
        {
          "detail": "The employee completes and signs Section 1 of Form I-9 no later than their first day of work.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Have the new hire complete Form I-9 Section 1 on or before the first day"
        },
        {
          "detail": "Examine the employee's original identity and work-authorization documents in person and complete Section 2 within three business days of the start date. duration_min (4320) is a conservative flat 72-hour calendar-hour floor, not a business-day calculator — it under-counts (is safe) when the window spans a weekend, so treat the actual three-business-day deadline as governing whenever it falls later than the flat 72-hour mark.\n\nWhy: 8 CFR §274a.2 sets a hard three-business-day deadline for Section 2 completion.",
          "id": "s4",
          "kind": "timer",
          "role": "hr",
          "timer_seconds": 259200,
          "title": "Complete Form I-9 Section 2 within three business days of the start date",
          "why": "8 CFR §274a.2 sets a hard three-business-day deadline for Section 2 completion."
        },
        {
          "detail": "Give the employee a written wage notice stating pay rate, pay basis, overtime rate, pay schedule, and employer information at or before the start of employment.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Provide the required wage notice at hire"
        },
        {
          "detail": "Have the employee complete Form W-4, sign confidentiality/handbook-acknowledgment placeholders, and any role-specific agreements.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Collect Form W-4 and required agreements"
        },
        {
          "detail": "Submit the new employee's information to the state new-hire reporting system within the state's required window.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "File the state new-hire report"
        },
        {
          "detail": "Store the signed offer, completed I-9, W-4, wage notice, and agreements.\n\nRecord: Store the signed offer, completed I-9, W-4, wage notice, and agreements in the personnel file per the retention schedule.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "File all completed paperwork in the personnel file"
        },
        {
          "detail": "Notify office-manager the paperwork is complete so system access and orientation (hro-005) can proceed on the start date.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Hand off to day-one onboarding"
        },
        {
          "detail": "Offer and pre-employment paperwork complete",
          "id": "s10",
          "kind": "step",
          "title": "Offer and pre-employment paperwork complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Offer letter and pre-employment paperwork (Form I-9 within three business days, W-4, wage notice, new-hire reporting, agreements) — An offer is accepted and a start date is set.",
      "title": "Offer letter and pre-employment paperwork (Form I-9 within three business days, W-4, wage notice, new-hire reporting, agreements)",
      "trigger": "An offer is accepted and a start date is set",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard, 29 CFR §1910.1030(g)(2) — training at time of initial assignment",
          "source": "OSHA Bloodborne Pathogens Standard, 29 CFR §1910.1030(g)(2) — training at time of initial assignment",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        },
        {
          "kind": "regulation",
          "label": "HIPAA workforce training, 45 CFR §164.530(b)",
          "source": "HIPAA workforce training, 45 CFR §164.530(b)"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "hro-005",
      "kind": "operational",
      "materials": [
        "orientation checklist",
        "OSHA bloodborne-pathogens training materials",
        "HIPAA workforce training materials",
        "system access request form",
        "buddy assignment list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager",
        "it-vendor",
        "all-staff",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Walk the new hire through clinical areas, break room, emergency exits, eyewash station, and posted emergency numbers.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Welcome and facility tour"
        },
        {
          "detail": "Pair the new hire with an experienced staff member for their first week for day-to-day questions.\n\nWhy: A new hire with no named point of contact defaults to guessing or interrupting the busiest person in the room.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign an onboarding buddy",
          "why": "A new hire with no named point of contact defaults to guessing or interrupting the busiest person in the room."
        },
        {
          "detail": "Request practice-management-system, email, and scheduling logins scoped to the new hire's role.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit system access request"
        },
        {
          "detail": "Wait for the IT vendor to provision the requested accounts and confirm working logins before the new hire touches any patient system.",
          "id": "s4",
          "kind": "timer",
          "role": "it-vendor",
          "timer_seconds": 3600,
          "title": "Wait for system access provisioning"
        },
        {
          "detail": "Complete initial bloodborne-pathogens exposure-control training covering exposure risks, PPE use, and the exposure-control plan.\n\nWhy: 29 CFR §1910.1030(g)(2) requires this training at the time of initial assignment.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Deliver OSHA bloodborne-pathogens orientation training",
          "why": "29 CFR §1910.1030(g)(2) requires this training at the time of initial assignment."
        },
        {
          "detail": "Cover PHI handling rules, minimum-necessary access, and the practice's breach-reporting process.\n\nWhy: 45 CFR §164.530(b) requires HIPAA training for all workforce members.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Deliver HIPAA workforce orientation training",
          "why": "45 CFR §164.530(b) requires HIPAA training for all workforce members."
        },
        {
          "detail": "Have the new hire sign an acknowledgment that OSHA and HIPAA orientation training was received before granting unsupervised patient-area access.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain signed training acknowledgment.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Obtain signed training acknowledgment"
        },
        {
          "detail": "Route the new hire to hro-006 for handbook issue and signed acknowledgment.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Hand off to handbook issue and acknowledgment"
        },
        {
          "detail": "File the signed orientation checklist, training acknowledgment, and access confirmation.\n\nRecord: File the signed orientation checklist, training acknowledgment, and system-access confirmation in the personnel file.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Record completed orientation checklist"
        },
        {
          "detail": "Day-one onboarding complete",
          "id": "s10",
          "kind": "step",
          "title": "Day-one onboarding complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Day-one onboarding (tour, system access, OSHA and HIPAA orientation, buddy) — A new employee's first day.",
      "title": "Day-one onboarding (tour, system access, OSHA and HIPAA orientation, buddy)",
      "trigger": "A new employee's first day",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §§201-203 (final pay obligations referenced in handbook policy)",
          "source": "California Labor Code §§201-203 (final pay obligations referenced in handbook policy)",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "generic",
          "label": "For an annual employment-law update review cycle — no vendor legal-update service named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for an annual employment-law update review cycle — no vendor legal-update service named"
          },
          "source": "For an annual employment-law update review cycle — no vendor legal-update service named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "annual",
      "id": "hro-006",
      "kind": "operational",
      "materials": [
        "current employee handbook",
        "annual legal-update checklist",
        "acknowledgment form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Identify why the handbook cycle was triggered",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-hire",
              "label": "New hire needs the current handbook"
            },
            {
              "goto": "s6",
              "id": "annual-review",
              "label": "Annual January 1 legal-update review is due"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "title": "Identify why the handbook cycle was triggered"
        },
        {
          "detail": "Provide the most recently reviewed version of the handbook, in print or through the onboarding system.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Issue the current handbook to the new hire"
        },
        {
          "detail": "Obtain a dated, signed statement from each employee confirming receipt and review of the current handbook.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Collect a signed acknowledgment from each employee"
        },
        {
          "detail": "Store each signed acknowledgment with the handbook version and effective date.\n\nRecord: Store each signed acknowledgment with the handbook version number and effective date in the personnel file.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "File the acknowledgment in the personnel file"
        },
        {
          "detail": "Handbook issue and acknowledgment complete",
          "id": "s5",
          "kind": "step",
          "title": "Handbook issue and acknowledgment complete"
        },
        {
          "detail": "Have qualified employment counsel review every policy against the current year's state and federal law changes before the updated handbook is issued to staff.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route the handbook for annual legal review before republishing.",
            "role": "employment counsel",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Route the handbook for annual legal review before republishing"
        },
        {
          "detail": "Distribute the legally reviewed handbook to every employee and note the effective date of the revision.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Publish the reviewed handbook to all staff"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Employee handbook issue, annual legal review and signed acknowledgment — Hire, every handbook revision, or a new law takes effect January 1.",
      "title": "Employee handbook issue, annual legal review and signed acknowledgment",
      "trigger": "Hire, every handbook revision, or a new law takes effect January 1",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For a structured 30/60/90-day new-hire review cadence — no institute program named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a structured 30/60/90-day new-hire review cadence — no institute program named"
          },
          "source": "For a structured 30/60/90-day new-hire review cadence — no institute program named — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "California Labor Code §2810.5 (written notice obligations referenced in onboarding review) and generic functional equivalent for a 30/60/90-day new-hire review cadence",
          "source": "California Labor Code §2810.5 (written notice obligations referenced in onboarding review) and generic functional equivalent for a 30/60/90-day new-hire review cadence",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "hro-007",
      "kind": "operational",
      "materials": [
        "check-in template",
        "competency checklist",
        "introductory-period review form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Meet with the new employee to review early performance, answer questions, and confirm competency-checklist progress.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Conduct the 30-day check-in"
        },
        {
          "detail": "Assess 30-day standing",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "on-track-30",
              "label": "On track — continue to day 60"
            },
            {
              "goto": "s8",
              "id": "concerns-30",
              "label": "Concerns identified — set an improvement plan"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Assess 30-day standing"
        },
        {
          "detail": "Review progress against the competency checklist and any 30-day improvement plan.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Conduct the 60-day check-in"
        },
        {
          "detail": "Complete the introductory-period review form covering job performance, attendance, and fit.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Conduct the 90-day check-in and introductory-period review"
        },
        {
          "detail": "Decide introductory-period outcome",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "pass-90",
              "label": "Introductory period passed — confirm regular status"
            },
            {
              "goto": "s9",
              "id": "extend-90",
              "label": "Extend the introductory period for more evaluation time"
            },
            {
              "goto": "s10",
              "id": "separation-90",
              "label": "Move toward separation instead of extending"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Decide introductory-period outcome"
        },
        {
          "detail": "Store the 30/60/90-day forms and any improvement plan in the personnel file.\n\nRecord: Store the 30/60/90-day forms and any improvement plan in the personnel file.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "File all check-in records"
        },
        {
          "detail": "30/60/90-day check-in cycle complete",
          "id": "s7",
          "kind": "step",
          "title": "30/60/90-day check-in cycle complete"
        },
        {
          "detail": "Write specific, measurable expectations and a follow-up date; share them with the employee in writing.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Document a 30-day improvement plan"
        },
        {
          "detail": "Get supervisor sign-off before extending the introductory period.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route an introductory-period extension to the practice owner.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "office-manager",
          "title": "Route an introductory-period extension to the practice owner"
        },
        {
          "detail": "Get practice-owner sign-off that a day-90 non-pass should proceed toward separation rather than extension, before handing off to the involuntary-termination protocol.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route a move-toward-separation outcome to the practice owner.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "office-manager",
          "title": "Route a move-toward-separation outcome to the practice owner"
        },
        {
          "detail": "Route this day-90 separation decision to hro-017 (involuntary termination — decision, meeting, final pay at separation, access revocation, continuation-coverage notices) so the wage-timing, COBRA/Cal-COBRA notice, and same-day access-revocation steps are not skipped.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the involuntary-termination protocol"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "30/60/90-day check-ins and introductory-period review — Days 30, 60 and 90 of employment.",
      "title": "30/60/90-day check-ins and introductory-period review",
      "trigger": "Days 30, 60 and 90 of employment",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Radiography certification requirements (Dental Board of California 16 CCR §1014.1, B&P §1656); CPR/BLS current certification per practice policy, not independently board-mandated for every role",
          "source": "Radiography certification requirements (Dental Board of California 16 CCR §1014.1, B&P §1656); CPR/BLS current certification per practice policy, not independently board-mandated for every role"
        },
        {
          "kind": "regulation",
          "label": "USCIS Form I-9 reverification obligations, 8 CFR §274a.2 (for time-limited work authorization)",
          "source": "USCIS Form I-9 reverification obligations, 8 CFR §274a.2 (for time-limited work authorization)",
          "url": "https://www.ecfr.gov/current/title-8/section-274a.2"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "monthly",
      "id": "hro-008",
      "kind": "operational",
      "materials": [
        "credential tracker",
        "state licensing board lookup",
        "renewal reminder template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Check every tracked credential's expiry date against today's date and flag anything within 60 days.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Run the monthly credential-expiry scan"
        },
        {
          "detail": "Evaluate scan result",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-flags",
              "label": "No credentials within 60 days of expiry"
            },
            {
              "goto": "s5",
              "id": "flags-found",
              "label": "One or more credentials flagged"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Evaluate scan result"
        },
        {
          "detail": "Record the scan date and that no credentials required action.\n\nRecord: Record the scan date and that no credentials required action.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Log the clean scan result"
        },
        {
          "detail": "Credential expiry tracking cycle complete",
          "id": "s4",
          "kind": "step",
          "title": "Credential expiry tracking cycle complete"
        },
        {
          "detail": "Send written notice naming the specific credential, its expiry date, and the renewal steps required.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Notify the affected employee"
        },
        {
          "detail": "Copy office-manager and compliance-officer on the flagged credential so scheduling can plan around a possible lapse.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Notify office-manager and compliance-officer"
        },
        {
          "detail": "Follow up weekly until the employee confirms renewal is scheduled or completed, and update the tracker with the new expiry date.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Track renewal progress until completed"
        },
        {
          "detail": "Check whether the credential lapses before renewal completes",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "renewed-in-time",
              "label": "Renewed before expiry"
            },
            {
              "goto": "s10",
              "id": "lapsed",
              "label": "Credential lapsed before renewal"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "title": "Check whether the credential lapses before renewal completes"
        },
        {
          "detail": "Log the new expiry date, renewal document reference, and any restricted-duty period.\n\nRecord: Log the new expiry date, renewal document reference, and any restricted-duty period in the credential tracker.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Update the credential tracker with the renewed expiry date"
        },
        {
          "detail": "A lapsed license, CPR/BLS card, radiography certification, or DEA permit means the employee must be restricted from the corresponding duties until renewal is confirmed; get compliance-officer sign-off before the employee resumes those duties.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate a lapsed clinical or regulated credential immediately.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Escalate a lapsed clinical or regulated credential immediately"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Credential expiry tracking (CPR/BLS, licenses, radiography, DEA, permits) with 60-day warnings — The monthly scan flags a credential within 60 days of expiry.",
      "title": "Credential expiry tracking (CPR/BLS, licenses, radiography, DEA, permits) with 60-day warnings",
      "trigger": "The monthly scan flags a credential within 60 days of expiry",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Radiography certification requirements (Dental Board of California 16 CCR §1014.1, B&P §1656); CPR/BLS current certification per practice policy, not independently board-mandated for every role",
          "source": "Radiography certification requirements (Dental Board of California 16 CCR §1014.1, B&P §1656); CPR/BLS current certification per practice policy, not independently board-mandated for every role"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California expanded-function delegation rules (16 CCR §1070-1096) — allowable duties require documented training and supervision level before delegation",
          "source": "Dental Board of California expanded-function delegation rules (16 CCR §1070-1096) — allowable duties require documented training and supervision level before delegation",
          "url": "https://www.dbc.ca.gov/laws_regs/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "hro-009",
      "kind": "operational",
      "materials": [
        "role skills checklist template",
        "expanded-function scope reference for the state",
        "competency sign-off form",
        "personnel file (physical or digital)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "hr",
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Open the skills checklist matching the new hire's job title (front desk, assistant, hygienist) or the specific new duty being added for an existing team member.\n\nWhy: A generic onboarding checklist misses the duties that carry a licensing or scope-of-practice line — the role checklist is the control document.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the role-specific skills checklist",
          "why": "A generic onboarding checklist misses the duties that carry a licensing or scope-of-practice line — the role checklist is the control document."
        },
        {
          "detail": "Does any listed duty require expanded-function delegation?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "Yes — one or more duties are expanded functions (e.g. coronal polishing, placing/removing matrices, taking impressions)"
            },
            {
              "goto": "s4",
              "id": "no",
              "label": "No — all duties are within the role's baseline scope with no delegation step"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does any listed duty require expanded-function delegation?"
        },
        {
          "detail": "Check the state dental practice act's allowable-duties table for the assistant/hygienist scope before assigning any expanded function; some duties require direct supervision, others general supervision.\n\nWhy: Delegating a duty outside the legal scope of the role is a licensing exposure for the supervising dentist, not just a training gap.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the duty is delegable under the state's expanded-function list",
          "why": "Delegating a duty outside the legal scope of the role is a licensing exposure for the supervising dentist, not just a training gap."
        },
        {
          "detail": "Go item by item through equipment operation, sterilization steps, chart documentation, and any expanded functions; the team member demonstrates each item and initials it themselves.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Walk the full role skills checklist with the team member"
        },
        {
          "detail": "Before the team member performs an expanded-function duty on a live patient for competency evaluation, the supervising dentist discloses to the patient that this is a first-time evaluation of that specific procedure for this team member and obtains their consent to proceed under direct supervision; if the patient declines, use a training model instead.\n\nWhy: Evaluating an as-yet-uncertified team member's competency on a real patient is a consent event in its own right, not a detail folded into the observation step.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain patient consent before a first-time competency evaluation on a live patient.",
            "type": "safety"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain patient consent before a first-time competency evaluation on a live patient",
          "why": "Evaluating an as-yet-uncertified team member's competency on a real patient is a consent event in its own right, not a detail folded into the observation step."
        },
        {
          "detail": "Watch the team member perform each expanded-function duty at least once on a live patient (per the consent gate just cleared) or a training model before marking it competent.\n\nWhy: Self-initialing a checklist item is not the same evidence as a supervisor watching the duty performed correctly.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Observe a live or simulated demonstration of each expanded function",
          "why": "Self-initialing a checklist item is not the same evidence as a supervisor watching the duty performed correctly."
        },
        {
          "detail": "The supervising dentist signs the competency sign-off form for each expanded function before the team member performs it unsupervised on a patient.\n\nWhy: Non-negotiable — the license backing an expanded function belongs to the supervising dentist, so their explicit sign-off is the gate, not a verbal go-ahead.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off required before first unsupervised delegation.",
            "role": "supervising dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off required before first unsupervised delegation",
          "why": "Non-negotiable — the license backing an expanded function belongs to the supervising dentist, so their explicit sign-off is the gate, not a verbal go-ahead."
        },
        {
          "detail": "Store the completed, signed checklist and competency sign-off form in the employee's personnel file with the date and the dentist's signature.\n\nRecord: role skills checklist, competency sign-off date, and supervising dentist signature in the personnel file",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "File the signed checklist and sign-off in the personnel record"
        },
        {
          "detail": "Set a reminder for 90 days out to re-observe any expanded function that had a rough first sign-off or low repetition volume.",
          "id": "s9",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 7776000,
          "title": "Schedule a 90-day competency recheck"
        },
        {
          "detail": "Competency sign-off complete",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Competency sign-off complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Role skills checklist and competency sign-off, including expanded-function verification before first delegation — A new hire, or a team member taking on a new duty or expanded function.",
      "title": "Role skills checklist and competency sign-off, including expanded-function verification before first delegation",
      "trigger": "A new hire, or a team member taking on a new duty or expanded function",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For buddy/mentor onboarding structure — no institute program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for buddy/mentor onboarding structure — no institute program reproduced"
          },
          "source": "For buddy/mentor onboarding structure — no institute program reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — generic functional equivalent for the remaining protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.1030(g)(2) requires training specifically 'at the time of initial assignment' and annually on bloodborne-pathogen exposure risk, PPE, the exposure control plan, and post-exposure procedures; 45 CFR 164.530(b) requires training workforce members on the covered entity's privacy policies and procedures. None of the five cited titles — shadowing/mentor pairing, cross-training rotation, lunch-and-learn/CE session, one-on-one coaching, new equipment/software rollout — names bloodborne-pathogen content or HIPAA privacy-policy content as their subject.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1030(g)(2) training at hire and annually; HIPAA workforce training 45 CFR 164.530(b)",
              "url": null
            }
          },
          "source": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "once",
      "id": "hro-010",
      "kind": "operational",
      "materials": [
        "mentor pairing list",
        "shadow schedule template",
        "30-day feedback form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pick a tenured team member in the same or an adjacent role and confirm they are willing and available to mentor for the first 30 days.\n\nWhy: A new hire with no named point of contact defaults to guessing or interrupting the busiest person in the room.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign a peer mentor on or before day one",
          "why": "A new hire with no named point of contact defaults to guessing or interrupting the busiest person in the room."
        },
        {
          "detail": "Hold a short introduction where the mentor explains their own role, the shadow schedule, and how to reach them during the shift.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Introduce mentor and new hire on day one"
        },
        {
          "detail": "Block out which shifts the new hire shadows the mentor directly versus works alongside them independently; post the schedule where both can see it.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Set the shadow schedule for week one"
        },
        {
          "detail": "Coach the mentor to narrate procedure and workflow to the shadowing new hire without reading identifying patient details aloud in earshot of other patients.\n\nWhy: Shadowing is a training activity, not a reason to relax the practice's normal privacy discipline at chairside.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Remind the mentor of patient-privacy limits while narrating chairside",
          "why": "Shadowing is a training activity, not a reason to relax the practice's normal privacy discipline at chairside."
        },
        {
          "detail": "Ask the mentor and the new hire separately each week what is working and what questions keep coming up; adjust the shadow schedule if either flags a gap.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Check in with mentor and new hire weekly"
        },
        {
          "detail": "Have the mentor and the new hire each fill out the 30-day feedback form on how the pairing went and whether continued mentoring is needed.\n\nRecord: 30-day mentor/new-hire feedback form in the personnel file",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect 30-day feedback from both sides"
        },
        {
          "detail": "Close out the formal pairing or extend it?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "close",
              "label": "Close the formal pairing — new hire is ready to work independently"
            },
            {
              "goto": "s3",
              "id": "extend",
              "label": "Extend the pairing another 30 days for a slower-ramping role"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Close out the formal pairing or extend it?"
        },
        {
          "detail": "Mentor pairing complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Mentor pairing complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Shadowing and mentor pairing for new team members — The first 30 days of employment.",
      "title": "Shadowing and mentor pairing for new team members",
      "trigger": "The first 30 days of employment",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For cross-training rotation planning — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for cross-training rotation planning — no vendor or consultancy program reproduced"
          },
          "source": "For cross-training rotation planning — no vendor or consultancy program reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — generic functional equivalent for the remaining protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.1030(g)(2) requires training specifically 'at the time of initial assignment' and annually on bloodborne-pathogen exposure risk, PPE, the exposure control plan, and post-exposure procedures; 45 CFR 164.530(b) requires training workforce members on the covered entity's privacy policies and procedures. None of the five cited titles — shadowing/mentor pairing, cross-training rotation, lunch-and-learn/CE session, one-on-one coaching, new equipment/software rollout — names bloodborne-pathogen content or HIPAA privacy-policy content as their subject.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1030(g)(2) training at hire and annually; HIPAA workforce training 45 CFR 164.530(b)",
              "url": null
            }
          },
          "source": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "quarterly",
      "id": "hro-011",
      "kind": "operational",
      "materials": [
        "role coverage matrix",
        "cross-training rotation calendar",
        "sign-off checklist per rotated duty"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull the current matrix showing which roles have only one trained person able to cover them, and mark every single-point-of-failure role.\n\nWhy: A single-point-of-failure role means one absence or resignation stops that function entirely — the matrix makes that risk visible instead of discovered mid-crisis.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the role coverage matrix",
          "why": "A single-point-of-failure role means one absence or resignation stops that function entirely — the matrix makes that risk visible instead of discovered mid-crisis."
        },
        {
          "detail": "Rank single-point-of-failure roles by how disruptive an absence would be (e.g. sterilization lead, insurance verification) and pick the top two or three to address this rotation.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Prioritize the highest-risk gaps for this quarter"
        },
        {
          "detail": "For each gap, name the current sole-trained person as trainer and select one willing team member as trainee; confirm both agree to the schedule.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Pair a trainer and a trainee for each prioritized gap"
        },
        {
          "detail": "Block specific shifts on the calendar where the trainee works the duty under the trainer's supervision, spaced across the quarter rather than crammed into one week.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the rotation calendar for the quarter"
        },
        {
          "detail": "As each trainee completes a supervised shift on the new duty, check it off the per-duty sign-off checklist; note any duty needing more repetitions.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the rotation and track sign-offs"
        },
        {
          "detail": "Is the trainee ready to cover the role solo by quarter end?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "on-track",
              "label": "On track — continue the scheduled rotation shifts"
            },
            {
              "goto": "s5",
              "id": "behind",
              "label": "Behind — add extra supervised shifts before quarter end"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the trainee ready to cover the role solo by quarter end?"
        },
        {
          "detail": "Mark newly cross-trained roles as covered by more than one person in the matrix and log the completed rotation in the quarterly HR summary.\n\nRecord: updated role coverage matrix and quarterly cross-training summary",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the coverage matrix at quarter end"
        },
        {
          "detail": "Quarterly cross-training rotation complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Quarterly cross-training rotation complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Cross-training rotation plan — The quarterly rotation plan is due, or a single-point-of-failure role is identified.",
      "title": "Cross-training rotation plan",
      "trigger": "The quarterly rotation plan is due, or a single-point-of-failure role is identified",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For in-office continuing-education session planning — no institute curriculum reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for in-office continuing-education session planning — no institute curriculum reproduced"
          },
          "source": "For in-office continuing-education session planning — no institute curriculum reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — generic functional equivalent for the remaining protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.1030(g)(2) requires training specifically 'at the time of initial assignment' and annually on bloodborne-pathogen exposure risk, PPE, the exposure control plan, and post-exposure procedures; 45 CFR 164.530(b) requires training workforce members on the covered entity's privacy policies and procedures. None of the five cited titles — shadowing/mentor pairing, cross-training rotation, lunch-and-learn/CE session, one-on-one coaching, new equipment/software rollout — names bloodborne-pathogen content or HIPAA privacy-policy content as their subject.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1030(g)(2) training at hire and annually; HIPAA workforce training 45 CFR 164.530(b)",
              "url": null
            }
          },
          "source": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "monthly",
      "id": "hro-012",
      "kind": "operational",
      "materials": [
        "session topic and presenter list",
        "sign-in sheet",
        "handout or slide deck",
        "attendance/CE credit log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Choose a topic from the backlog (new material, device, updated protocol, or a compliance refresher) or confirm the topic prompted by a recent change in the office.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pick the session topic"
        },
        {
          "detail": "Ask the dentist, a vendor rep, or a team member with relevant expertise to prepare a short presentation or demonstration for the session.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign a presenter"
        },
        {
          "detail": "Book the session over a lunch block or a scheduled admin period so it does not compete with patient care; confirm coverage for phones during the session.\n\nWhy: A training session that pulls the whole team off the floor without phone coverage creates a service gap the session itself doesn't justify.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the session during a low-patient-volume window",
          "why": "A training session that pulls the whole team off the floor without phone coverage creates a service gap the session itself doesn't justify."
        },
        {
          "detail": "Run the presentation or hands-on demonstration; circulate a sign-in sheet and distribute any handout or reference material.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Hold the session"
        },
        {
          "detail": "Record who attended and whether the session qualifies for continuing-education credit in the attendance/CE credit log.\n\nRecord: attendance/CE credit log entry for the session",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log attendance and any CE credit"
        },
        {
          "detail": "Ask attendees for a one-line reaction and any topic requests for next month; add requests to the topic backlog.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect quick feedback on the topic and format"
        },
        {
          "detail": "Session complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Session complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Lunch-and-learn or in-office CE session — The monthly session date arrives, or a new material, device or protocol needs team training.",
      "title": "Lunch-and-learn or in-office CE session",
      "trigger": "The monthly session date arrives, or a new material, device or protocol needs team training",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Penal Code §632 — all-party consent before recording or reviewing a call recording",
          "source": "California Penal Code §632 — all-party consent before recording or reviewing a call recording",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=632.&lawCode=PEN"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.514(d) minimum necessary — call review limited to what is needed to coach the call handling",
          "source": "HIPAA 45 CFR 164.514(d) minimum necessary — call review limited to what is needed to coach the call handling",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 30,
      "frequency": "weekly",
      "id": "hro-013",
      "kind": "operational",
      "materials": [
        "call scoring rubric",
        "consented call recording access or live observation slot",
        "coaching notes template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Verify the call recording being reviewed carries the all-party consent disclosure required by California Penal Code §632, or that this is a live-observation slot the caller was not told is a private line.\n\nWhy: Reviewing an unconsented recording is a §632 exposure regardless of the coaching intent behind it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the call was consented for recording or review.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm the call was consented for recording or review",
          "why": "Reviewing an unconsented recording is a §632 exposure regardless of the coaching intent behind it."
        },
        {
          "detail": "Select a representative sample of the week's consented recordings (mix of new patient, scheduling, and difficult-caller calls) or schedule a live-observation window.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the weekly sample of consented calls"
        },
        {
          "detail": "Rate greeting, needs discovery, scheduling accuracy, tone, and close on the call scoring rubric for each sampled call.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Score each call against the rubric"
        },
        {
          "detail": "Look across the week's scored calls for a pattern (e.g. consistently skipping insurance questions, strong rapport but slow scheduling) rather than treating each call as an isolated event.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify recurring strengths and gaps across the sample"
        },
        {
          "detail": "Walk through one or two specific call moments with the team member, naming what worked and one concrete change to try next week.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Hold a short coaching conversation with the call handler"
        },
        {
          "detail": "Record the scores, the pattern identified, and the agreed next step in the coaching notes template, filed with the team member's development record.\n\nRecord: call scoring results and coaching notes in the team member's development file",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the coaching notes"
        },
        {
          "detail": "Weekly call audit and coaching complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Weekly call audit and coaching complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Phone-call audit and coaching session (consented recordings or live observation) — A weekly sample of consented recordings or live observation.",
      "title": "Phone-call audit and coaching session (consented recordings or live observation)",
      "trigger": "A weekly sample of consented recordings or live observation",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For one-on-one manager coaching conversations — no vendor curriculum reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for one-on-one manager coaching conversations — no vendor curriculum reproduced"
          },
          "source": "For one-on-one manager coaching conversations — no vendor curriculum reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — generic functional equivalent for the remaining protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.1030(g)(2) requires training specifically 'at the time of initial assignment' and annually on bloodborne-pathogen exposure risk, PPE, the exposure control plan, and post-exposure procedures; 45 CFR 164.530(b) requires training workforce members on the covered entity's privacy policies and procedures. None of the five cited titles — shadowing/mentor pairing, cross-training rotation, lunch-and-learn/CE session, one-on-one coaching, new equipment/software rollout — names bloodborne-pathogen content or HIPAA privacy-policy content as their subject.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1030(g)(2) training at hire and annually; HIPAA workforce training 45 CFR 164.530(b)",
              "url": null
            }
          },
          "source": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hro-014",
      "kind": "operational",
      "materials": [
        "one-on-one conversation template",
        "prior notes from the last conversation",
        "growth/development tracker"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull up the last one-on-one's notes and any open action items before the meeting so the conversation continues rather than restarts.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Review notes from the prior conversation"
        },
        {
          "detail": "Meet somewhere out of earshot of patients and coworkers; ask open questions about workload, blockers, and how the team member is doing before giving any feedback.\n\nWhy: A coaching conversation held at the front desk in earshot of others suppresses honest answers and can expose whatever is being discussed to bystanders.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Hold the conversation in a private space",
          "why": "A coaching conversation held at the front desk in earshot of others suppresses honest answers and can expose whatever is being discussed to bystanders."
        },
        {
          "detail": "Share one specific recent strength and one specific area to work on; ask the team member for their own feedback on support they need from management.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Give specific, recent feedback in both directions"
        },
        {
          "detail": "Land on a single concrete action item either side will do before the next scheduled one-on-one, rather than a long list that won't get tracked.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Agree on one action item before the next conversation"
        },
        {
          "detail": "Write a brief summary of what was discussed and the agreed action item into the growth/development tracker.\n\nRecord: one-on-one summary and action item in the growth/development tracker",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the conversation notes"
        },
        {
          "detail": "Book the next one-on-one now, at weekly cadence for a team member under 90 days and monthly for tenured staff.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the next conversation"
        },
        {
          "detail": "One-on-one coaching conversation complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "One-on-one coaching conversation complete"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "One-on-one coaching conversation — Weekly for new team members, monthly for tenured.",
      "title": "One-on-one coaching conversation",
      "trigger": "Weekly for new team members, monthly for tenured",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For new-system training rollout planning — no vendor program name reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for new-system training rollout planning — no vendor program name reproduced"
          },
          "source": "For new-system training rollout planning — no vendor program name reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — generic functional equivalent for the remaining protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.1030(g)(2) requires training specifically 'at the time of initial assignment' and annually on bloodborne-pathogen exposure risk, PPE, the exposure control plan, and post-exposure procedures; 45 CFR 164.530(b) requires training workforce members on the covered entity's privacy policies and procedures. None of the five cited titles — shadowing/mentor pairing, cross-training rotation, lunch-and-learn/CE session, one-on-one coaching, new equipment/software rollout — names bloodborne-pathogen content or HIPAA privacy-policy content as their subject.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.1030(g)(2) training at hire and annually; HIPAA workforce training 45 CFR 164.530(b)",
              "url": null
            }
          },
          "source": "No single regulation governs this set. OSHA 29 CFR 1910.1030(g)(2) mandates Bloodborne Pathogens exposure-control training at hire and annually; 45 CFR 164.530(b) mandates HIPAA privacy-policy workforce training. Neither reaches general HR/operations development activity — Practice policy — no published authority governs this step."
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "hro-015",
      "kind": "operational",
      "materials": [
        "vendor training materials",
        "rollout schedule",
        "competency checklist for the new system",
        "support contact sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "it-vendor",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Arrange the vendor's or installer's initial training session for the office manager and one or two super-users before the wider team rollout.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Schedule vendor or install training"
        },
        {
          "detail": "Does the system offer a training or demo environment separate from live patient data?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "Yes — use the training/demo environment for hands-on practice"
            },
            {
              "goto": "s10",
              "id": "no",
              "label": "No — practice will touch live records; restrict practice to read-only or non-patient test entries"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the system offer a training or demo environment separate from live patient data?"
        },
        {
          "detail": "Stagger training in small groups by role over the transition window so patient care coverage is maintained; identify which roles need which depth of training.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the staged rollout schedule"
        },
        {
          "detail": "Walk each group through the core workflows they'll use daily, using the training/demo environment where available; have each attendee complete a supervised practice run.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the training sessions"
        },
        {
          "detail": "Have each trained team member complete their key task (e.g. schedule an appointment, post a charge, capture an image) unsupervised and check it off the competency checklist.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm each staff member can complete their core workflow independently"
        },
        {
          "detail": "Is the team ready for go-live?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "ready",
              "label": "Ready — enough staff are competent to run the system in production"
            },
            {
              "goto": "s4",
              "id": "not-ready",
              "label": "Not ready — run additional sessions before go-live"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the team ready for go-live?"
        },
        {
          "detail": "Cut over to the new system on the scheduled date, with the support contact sheet posted and a super-user available on-site for the first days.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Go live with the new system"
        },
        {
          "detail": "Record the go-live date, who completed training, and any open issues or support tickets from the first 30 days.\n\nRecord: rollout log with training completion and first-30-days support tickets",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the rollout and open issues"
        },
        {
          "detail": "New system training rollout complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "New system training rollout complete"
        },
        {
          "detail": "Before scheduling any hands-on practice on the live system, get the IT vendor to confirm and check off that accounts are set to read-only, or that only non-patient test entries are reachable, and verify by attempting a non-test action fails as expected.\n\nWhy: Naming the restriction as an option label is not the same as verifying it was configured — this checklist is the only checkpoint against live PHI exposure during training on this path.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm restricted practice mode is actually configured before hands-on training",
          "why": "Naming the restriction as an option label is not the same as verifying it was configured — this checklist is the only checkpoint against live PHI exposure during training on this path."
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "New equipment or software training rollout — A new system or device is purchased.",
      "title": "New equipment or software training rollout",
      "trigger": "A new system or device is purchased",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §202 — final wages due within 72 hours of resignation without notice, or immediately if 72 hours' notice was given",
          "source": "California Labor Code §202 — final wages due within 72 hours of resignation without notice, or immediately if 72 hours' notice was given",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "California Labor Code §227.3 — accrued, unused vacation paid out as wages at final pay",
          "source": "California Labor Code §227.3 — accrued, unused vacation paid out as wages at final pay"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hro-016",
      "kind": "operational",
      "materials": [
        "resignation acknowledgment form",
        "final-pay calculation worksheet",
        "system access list",
        "key/badge/equipment return checklist",
        "exit interview template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager",
        "it-vendor",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Get the resignation in writing where possible, note the last working day, and acknowledge receipt to the team member the same day.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and acknowledge the resignation"
        },
        {
          "detail": "Did the team member resign with notice, or walk out mid-shift?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "notice",
              "label": "Resigned with advance notice — normal timeline applies"
            },
            {
              "goto": "s10",
              "id": "walkout",
              "label": "Walked out mid-shift with no notice — treat as immediate separation"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the team member resign with notice, or walk out mid-shift?"
        },
        {
          "detail": "Calculate all wages owed plus accrued unused vacation using the final-pay calculation worksheet; issue the final paycheck within 72 hours of resignation if no notice was given, or on the last day if 72 hours' notice was given.\n\nWhy: California Labor Code §202/§203 penalizes late final wages by the day — this is a compliance deadline, not a courtesy.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Calculate final pay due within 72 hours",
          "why": "California Labor Code §202/§203 penalizes late final wages by the day — this is a compliance deadline, not a courtesy."
        },
        {
          "detail": "Have the practice owner or office manager confirm the final-pay calculation and the access-revocation list before either is executed.\n\nWhy: Final pay and system access are money and security consequences — a second set of eyes before execution catches calculation errors and access-list omissions.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor review before final pay and access revocation are executed.",
            "role": "practice owner or office manager",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Supervisor review before final pay and access revocation are executed",
          "why": "Final pay and system access are money and security consequences — a second set of eyes before execution catches calculation errors and access-list omissions."
        },
        {
          "detail": "Send the system access list to IT/vendor support for same-day revocation of practice-management software, email, EHR, building alarm codes, and any shared logins on the departing team member's last working day.\n\nWhy: Delayed access revocation on a resignation leaves patient records and financial systems reachable by someone no longer accountable to the practice.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off same-day access revocation to IT",
          "why": "Delayed access revocation on a resignation leaves patient records and financial systems reachable by someone no longer accountable to the practice."
        },
        {
          "detail": "Collect building keys, access badges, uniforms, and any practice-owned equipment (laptop, pager, loupes) on the last day using the key/badge/equipment return checklist.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect keys, badges and practice-owned equipment"
        },
        {
          "detail": "Ask about reason for leaving, what worked well, and what could improve, using the exit interview template; note any concerns that need owner follow-up.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Conduct an exit interview"
        },
        {
          "detail": "File the resignation acknowledgment, final-pay documentation, access-revocation confirmation, property return checklist, and exit interview notes in the personnel file.\n\nRecord: resignation acknowledgment, final-pay record, access-revocation confirmation, and exit interview notes in the personnel file",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "File the complete offboarding record"
        },
        {
          "detail": "Resignation offboarding complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Resignation offboarding complete"
        },
        {
          "detail": "Treat a mid-shift walkout as a resignation with no notice; calculate final pay including accrued vacation and issue it within 72 hours per the same statutory deadline.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Calculate and issue final pay immediately"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Resignation offboarding (notice period, final pay, access revocation, keys, exit interview) — A team member submits a resignation or walks out mid-shift.",
      "title": "Resignation offboarding (notice period, final pay, access revocation, keys, exit interview)",
      "trigger": "A team member submits a resignation or walks out mid-shift",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §201–203 — final wages due immediately at involuntary termination",
          "source": "California Labor Code §201–203 — final wages due immediately at involuntary termination",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "California Unemployment Insurance Code §1089 — For Your Benefit pamphlet given at termination",
          "source": "California Unemployment Insurance Code §1089 — For Your Benefit pamphlet given at termination"
        },
        {
          "kind": "statute",
          "label": "COBRA 29 U.S.C. §1161 / Cal-COBRA, Health & Safety Code §1366.20 et seq. (HMO/health-care-service-plan coverage) — continuation coverage election notice",
          "source": "COBRA 29 U.S.C. §1161 / Cal-COBRA, Health & Safety Code §1366.20 et seq. (HMO/health-care-service-plan coverage) — continuation coverage election notice"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hro-017",
      "kind": "operational",
      "materials": [
        "personnel file",
        "documented performance or conduct record",
        "final paycheck calculation",
        "COBRA/Cal-COBRA notice packet",
        "unemployment insurance pamphlet",
        "termination checklist",
        "access-revocation ticket"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "hr",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Practice owner and HR review the personnel file: documented performance issues, prior warnings, or the conduct incident, and confirm the decision is not retaliatory or discriminatory (protected class, leave status, whistleblower activity).\n\nWhy: An undocumented or retaliation-adjacent termination is the single highest-severity HR liability a small practice faces; the gate exists to force a second set of eyes before the meeting is scheduled.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner and HR review documented basis for termination.",
            "role": "practice-owner + hr",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner and HR review documented basis for termination",
          "why": "An undocumented or retaliation-adjacent termination is the single highest-severity HR liability a small practice faces; the gate exists to force a second set of eyes before the meeting is scheduled."
        },
        {
          "detail": "HR calculates final wages owed (regular hours, overtime, accrued unused vacation/PTO) and prepares the final paycheck for delivery at the meeting, along with the required unemployment insurance pamphlet and any Cal-COBRA/COBRA notice.\n\nWhy: California requires final wages at the moment of involuntary separation, not the next pay cycle — a late final check triggers waiting-time penalties.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Prepare final paycheck and separation packet",
          "why": "California requires final wages at the moment of involuntary separation, not the next pay cycle — a late final check triggers waiting-time penalties."
        },
        {
          "detail": "Schedule the meeting in a private room, outside patient view and hearing, at a time that minimizes disruption (end of day or before opening). A second manager or HR representative attends as a witness.\n\nWhy: A witness protects both the employee and the practice from later disputes about what was said, and a private setting preserves the employee's dignity.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the meeting privately, with a witness",
          "why": "A witness protects both the employee and the practice from later disputes about what was said, and a private setting preserves the employee's dignity."
        },
        {
          "detail": "State the decision clearly and briefly, without re-litigating the history in detail. Hand over the final paycheck and separation packet. Collect keys, badge, and any practice property. Keep the meeting under 10 minutes.\n\nWhy: A short, factual meeting reduces escalation risk and keeps the record consistent with the documented basis.\n\nRecord: date, time, attendees, and a brief factual summary of what was said, filed in the personnel record",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Conduct the termination meeting",
          "why": "A short, factual meeting reduces escalation risk and keeps the record consistent with the documented basis."
        },
        {
          "detail": "Office manager hands the terminated employee's name and all system logins (practice management software, email, scheduling, building/alarm codes, shared drives) to the IT vendor for immediate revocation.\n\nWhy: Delayed access revocation is a documented breach vector — a terminated employee with lingering system access can view or alter patient records.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to IT for same-day access revocation",
          "why": "Delayed access revocation is a documented breach vector — a terminated employee with lingering system access can view or alter patient records."
        },
        {
          "detail": "IT vendor confirms and checks off: practice management software login disabled, email account disabled or forwarded, building alarm code changed if shared, physical key or fob deactivated, any remote-access VPN or cloud storage account removed.\n\nWhy: A checklist prevents a single missed system from becoming an open door.\n\nRecord: signed-off access-revocation checklist in the personnel file",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Confirm every access point is revoked",
          "why": "A checklist prevents a single missed system from becoming an open door."
        },
        {
          "detail": "Cross-check the paycheck amount physically handed over during the meeting against the final-pay calculation worksheet (regular hours, overtime, accrued unused vacation/PTO) to confirm it is accurate and complete, not a placeholder or estimate pending correction.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "delivered",
              "label": "Amount matches the final-pay calculation — nothing further owed"
            },
            {
              "goto": "s12",
              "id": "not-ready",
              "label": "Amount was incomplete, incorrect, or not delivered at all"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "hr",
          "title": "Confirm the amount handed over at the meeting was the correct final calculation"
        },
        {
          "detail": "Mail or hand-deliver the COBRA/Cal-COBRA election notice and any retirement-plan or benefits-continuation paperwork within the required notice window; log the mailing date.\n\nWhy: Missing the continuation-coverage notice deadline exposes the practice to plan-level penalties independent of the termination itself.\n\nRecord: mailing date and method for COBRA/Cal-COBRA and benefits notices",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Send continuation-coverage and benefits notices",
          "why": "Missing the continuation-coverage notice deadline exposes the practice to plan-level penalties independent of the termination itself."
        },
        {
          "detail": "File a copy of the documented basis, the meeting summary, and the pamphlet acknowledgment in the personnel file, ready to support or respond to an unemployment insurance claim.\n\nRecord: complete separation packet filed in the personnel record",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "File the separation record for unemployment claims"
        },
        {
          "detail": "Office manager tells the remaining team only that the position is open and reassigns immediate duties; no details of the reason are shared with staff.\n\nWhy: Oversharing termination reasons with remaining staff creates defamation exposure and damages morale beyond what the situation requires.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the remaining team factually and minimally",
          "why": "Oversharing termination reasons with remaining staff creates defamation exposure and damages morale beyond what the situation requires."
        },
        {
          "detail": "Personnel file, access log, and benefits notices are complete; the position is marked open if backfilling.",
          "id": "s11",
          "kind": "step",
          "title": "Termination closed out"
        },
        {
          "detail": "HR immediately escalates to the practice owner to issue a corrected or same-day final check by hand or courier; document the reason for the shortfall or delay and the corrective delivery time.\n\nWhy: Every day the final check is late or short accrues a waiting-time penalty under California law — expediting the correction caps the exposure.",
          "id": "s12",
          "kind": "step",
          "role": "hr",
          "title": "Escalate and correct an inaccurate or undelivered final payment",
          "why": "Every day the final check is late or short accrues a waiting-time penalty under California law — expediting the correction caps the exposure."
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Involuntary termination — decision, meeting, final pay at separation, access revocation, continuation-coverage notices — The owner decides to terminate an employee for performance, conduct or position elimination.",
      "title": "Involuntary termination — decision, meeting, final pay at separation, access revocation, continuation-coverage notices",
      "trigger": "The owner decides to terminate an employee for performance, conduct or position elimination",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Education Code §49110 / Labor Code §1391 — work permit (Form B1-1) required for minors under 18 before employment",
          "source": "California Education Code §49110 / Labor Code §1391 — work permit (Form B1-1) required for minors under 18 before employment",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "regulation",
          "label": "Federal Fair Labor Standards Act child labor provisions, Hazardous Occupations Orders, 29 CFR Part 570 — hour limits and prohibited duties for minors",
          "source": "Federal Fair Labor Standards Act child labor provisions, Hazardous Occupations Orders, 29 CFR Part 570 — hour limits and prohibited duties for minors",
          "url": "https://www.ecfr.gov/current/title-29/part-570"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — occupational exposure control applies regardless of age",
          "source": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — occupational exposure control applies regardless of age",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "hro-018",
      "kind": "operational",
      "materials": [
        "work-permit application (Form B1-1)",
        "school contact information",
        "proposed schedule",
        "duty description",
        "hazardous-duty exclusion list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "HR confirms the applicant is under 18 and currently enrolled in school (or has graduated/is exempt), and records which category applies since permit and hour rules differ for enrolled minors.\n\nWhy: Work-permit and hour-limit rules turn on both age and school-enrollment status, so getting this wrong upstream misconfigures the whole schedule.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Confirm the applicant's age and school enrollment status",
          "why": "Work-permit and hour-limit rules turn on both age and school-enrollment status, so getting this wrong upstream misconfigures the whole schedule."
        },
        {
          "detail": "HR checks the proposed duties against the prohibited list: no operation of sterilization autoclaves, no handling of hazardous chemicals, no exposure-prone clinical tasks, no work involving direct blood/OPIM contact. Confirm the role is limited to front-desk, filing, non-hazardous sterilization-area support under direct supervision, or similar.\n\nWhy: Federal Hazardous Occupations Orders bar minors from many tasks common in a dental office's back area; scoping the job description correctly up front avoids an unlawful assignment later.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Define permitted duties for this role",
          "why": "Federal Hazardous Occupations Orders bar minors from many tasks common in a dental office's back area; scoping the job description correctly up front avoids an unlawful assignment later."
        },
        {
          "detail": "Check whether the applicant holds a current work permit naming this practice as employer.",
          "forks": [
            {
              "advised": false,
              "goto": "s5",
              "id": "has-permit",
              "label": "Valid permit already on file"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "needs-permit",
              "label": "No permit — must be obtained before first shift"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hr",
          "title": "Does the minor already have a valid work permit for this employer?"
        },
        {
          "detail": "HR provides the minor the work-permit application, which the minor's school issuing officer completes and signs (Form B1-1 or state equivalent), naming the practice, proposed hours, and duties. The signed permit is returned before any work begins.\n\nWhy: In California, working a minor before the permit is issued is itself a violation, independent of the hours or duties assigned.\n\nRecord: signed work permit filed in the personnel file",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Obtain the work permit before the minor's first shift",
          "why": "In California, working a minor before the permit is issued is itself a violation, independent of the hours or duties assigned."
        },
        {
          "detail": "Office manager builds the shift schedule within the applicable limits (e.g., school-day and non-school-day caps, no work during school hours unless enrolled in a work-study program, required meal-period timing), cross-checked against the school calendar.\n\nWhy: Hour limits are stricter on school days and during the school year — building the schedule against the school calendar prevents an inadvertent overshift.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Build a schedule within legal hour limits",
          "why": "Hour limits are stricter on school days and during the school year — building the schedule against the school calendar prevents an inadvertent overshift."
        },
        {
          "detail": "Office manager assigns a specific adult staff member as the on-shift supervisor for the minor, responsible for keeping the minor within permitted duties.\n\nWhy: A minor working without a named supervisor is how a permitted duty quietly drifts into a prohibited one.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign a direct supervisor for every shift",
          "why": "A minor working without a named supervisor is how a permitted duty quietly drifts into a prohibited one."
        },
        {
          "detail": "Office manager verifies the signed permit is on file and the written duty description excludes all hazardous tasks before allowing the minor's first shift to start.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm permit and duty scope before first shift begins.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm permit and duty scope before first shift begins"
        },
        {
          "detail": "Cover the permitted duty list explicitly, where the minor may and may not go in the clinical area, and who to ask before doing anything not on the list.\n\nWhy: An explicit boundary conversation on day one is the practical control against duty creep once the minor is comfortable and eager to help.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Deliver a duty-scoped day-one orientation",
          "why": "An explicit boundary conversation on day one is the practical control against duty creep once the minor is comfortable and eager to help."
        },
        {
          "detail": "Work permit, duty description, schedule template, and supervisor assignment are filed together in the personnel record.\n\nRecord: minor-employment packet (permit, duties, schedule, supervisor) filed",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "File the complete minor-employment record"
        },
        {
          "detail": "Permit on file, duties scoped, schedule compliant, supervisor assigned.",
          "id": "s10",
          "kind": "step",
          "title": "Minor employee onboarded within legal limits"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Hiring a minor — work permit, hour limits and prohibited duties — A high-school student applies for a front-desk or sterilization role.",
      "title": "Hiring a minor — work permit, hour limits and prohibited duties",
      "trigger": "A high-school student applies for a front-desk or sterilization role",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California 16 CCR §1014.1 (radiography certification), B&P §1656 — RDH/RDA license and radiography permit must be verified active before duties begin",
          "source": "Dental Board of California 16 CCR §1014.1 (radiography certification), B&P §1656 — RDH/RDA license and radiography permit must be verified active before duties begin",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "HHS-OIG exclusion screening 42 CFR 1001.1901 — exclusion check before any billing-adjacent duties",
          "source": "HHS-OIG exclusion screening 42 CFR 1001.1901 — exclusion check before any billing-adjacent duties"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030(g)(2) — training at time of initial assignment applies to temporary staff",
          "source": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030(g)(2) — training at time of initial assignment applies to temporary staff",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "hro-019",
      "kind": "operational",
      "materials": [
        "license verification lookup",
        "radiography permit verification",
        "temporary access badge or login",
        "practice safety-data-sheet binder location",
        "sterilization protocol quick-reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager looks up the temp's RDH/RDA license (or applicable credential) on the state licensing board's public verification site and confirms it is active and unrestricted before the shift begins.\n\nWhy: A lapsed or restricted license is an immediate scope-of-practice violation the moment the temp touches a patient.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the temp's license or registration is active",
          "why": "A lapsed or restricted license is an immediate scope-of-practice violation the moment the temp touches a patient."
        },
        {
          "detail": "Confirm whether the shift will involve exposing radiographs.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes-xray",
              "label": "Yes — radiography permit verification required"
            },
            {
              "goto": "s4",
              "id": "no-xray",
              "label": "No radiography duties today"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Will the temp be taking radiographs today?"
        },
        {
          "detail": "Confirm the temp holds a current radiography permit or certificate separate from the base license, per state requirements.\n\nWhy: Radiography authorization is often a separate credential from the base license and is commonly overlooked for short-notice temps.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify radiography permit is current",
          "why": "Radiography authorization is often a separate credential from the base license and is commonly overlooked for short-notice temps."
        },
        {
          "detail": "Office manager checks the temp's name against the HHS-OIG List of Excluded Individuals/Entities before allowing any billing-adjacent involvement.\n\nWhy: Employing an excluded individual, even for a single shift, creates federal program billing exposure.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Run a quick exclusion-list check",
          "why": "Employing an excluded individual, even for a single shift, creates federal program billing exposure."
        },
        {
          "detail": "Office manager confirms all three checks (license, radiography permit if applicable, exclusion list) cleared before the temp sees any patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm license, permit and exclusion checks clear before the first patient.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm license, permit and exclusion checks clear before the first patient"
        },
        {
          "detail": "Cover, in under 10 minutes: emergency exits and the emergency code/response, location of the safety-data-sheet binder, sterilization protocol quick-reference, where PPE is kept, and today's schedule.\n\nWhy: A temp cannot safely improvise emergency response or sterilization steps on a single shift without a fast, structured orientation.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Deliver a compressed safety and workflow orientation",
          "why": "A temp cannot safely improvise emergency response or sterilization steps on a single shift without a fast, structured orientation."
        },
        {
          "detail": "Office manager issues a temporary login or badge scoped to only what the shift requires, flagged for same-day expiration.\n\nWhy: A temp's access should never outlive the shift — scoping it up front makes end-of-shift revocation a single deactivation rather than a hunt.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Issue a scoped, time-limited system access credential",
          "why": "A temp's access should never outlive the shift — scoping it up front makes end-of-shift revocation a single deactivation rather than a hunt."
        },
        {
          "detail": "Dentist or office manager names a specific staff member the temp can ask questions of throughout the shift.\n\nWhy: An unfamiliar environment produces more questions than a returning employee would have — a named contact prevents guessing.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Assign a point-of-contact for the shift",
          "why": "An unfamiliar environment produces more questions than a returning employee would have — a named contact prevents guessing."
        },
        {
          "detail": "At shift end: revoke or expire the temporary login/badge, collect any keys or access items issued, confirm the temp's hours for agency billing, and note any incidents.\n\nRecord: shift-end checklist with access-revocation timestamp",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Close out the temp's shift"
        },
        {
          "detail": "Credentials verified, access revoked, hours logged.",
          "id": "s10",
          "kind": "step",
          "title": "Temporary staff shift closed out"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Same-day temporary hygienist or assistant onboarding (license, radiography, scope, access) — An agency or marketplace temp arrives for a single shift.",
      "title": "Same-day temporary hygienist or assistant onboarding (license, radiography, scope, access)",
      "trigger": "An agency or marketplace temp arrives for a single shift",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA workforce/volunteer confidentiality obligations 45 CFR 164.530(b) — non-employee observers with PHI exposure need a confidentiality agreement and training",
          "source": "HIPAA workforce/volunteer confidentiality obligations 45 CFR 164.530(b) — non-employee observers with PHI exposure need a confidentiality agreement and training",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — observer/extern exposure control and PPE requirements",
          "source": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — observer/extern exposure control and PPE requirements",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "hro-020",
      "kind": "operational",
      "materials": [
        "school/program affiliation agreement",
        "confidentiality (HIPAA) acknowledgment form",
        "immunization/health-clearance record",
        "observer badge",
        "patient-consent script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager collects the requesting school or program's contact information, the dates requested, and whether the placement is a formal externship (school-affiliated, may require a program agreement) or an informal shadow day.\n\nWhy: A formal externship often carries its own program-level agreement and insurance requirements that an informal shadow day does not.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Intake the placement request",
          "why": "A formal externship often carries its own program-level agreement and insurance requirements that an informal shadow day does not."
        },
        {
          "detail": "Determine whether a program-level affiliation agreement is required.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "formal",
              "label": "Formal externship — program agreement required"
            },
            {
              "goto": "s4",
              "id": "informal",
              "label": "Informal one-day shadow"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a formal school-affiliated externship?"
        },
        {
          "detail": "Office manager obtains the signed program agreement (liability, insurance, scope of activities) from the school before scheduling the placement date.\n\nWhy: The affiliation agreement is where liability and insurance responsibility for the extern is formally assigned — skipping it leaves the practice exposed if the extern is injured or causes harm.\n\nRecord: signed affiliation agreement filed",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect the signed school affiliation agreement",
          "why": "The affiliation agreement is where liability and insurance responsibility for the extern is formally assigned — skipping it leaves the practice exposed if the extern is injured or causes harm."
        },
        {
          "detail": "Before entering any clinical area, the observer signs a confidentiality acknowledgment covering HIPAA obligations — no photos, no discussion of what they see outside the practice, no access to records beyond what a supervising provider shows them.\n\nWhy: An observer is workforce-adjacent for HIPAA purposes the moment they can see or hear patient information, so the confidentiality obligation has to be in place before the first encounter, not after.\n\nRecord: signed confidentiality acknowledgment filed",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Have the observer sign a confidentiality acknowledgment",
          "why": "An observer is workforce-adjacent for HIPAA purposes the moment they can see or hear patient information, so the confidentiality obligation has to be in place before the first encounter, not after."
        },
        {
          "detail": "Confirm current immunization or health-clearance documentation is on file where the school program requires it, and issue appropriate PPE (mask, gloves, eyewear) sized for the observer.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm health-clearance and PPE readiness"
        },
        {
          "detail": "Before the observer enters a treatment room, the treating provider asks the patient whether they're comfortable with a student observer present and documents the answer; the observer steps out if the patient declines.\n\nWhy: A patient's consent to their own dentist does not extend to an audience, and declining must have zero friction for the patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain patient consent before each observed encounter.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain patient consent before each observed encounter",
          "why": "A patient's consent to their own dentist does not extend to an audience, and declining must have zero friction for the patient."
        },
        {
          "detail": "Cover: observe only, do not touch instruments or the patient unless directly invited by the supervising provider, step back immediately if a patient becomes uncomfortable, and where to stand to stay out of the sterile field.\n\nWhy: An untrained observer can unintentionally break a sterile field or startle an anxious patient without knowing the norms.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief the observer on conduct and boundaries",
          "why": "An untrained observer can unintentionally break a sterile field or startle an anxious patient without knowing the norms."
        },
        {
          "detail": "Issue a badge clearly marked 'Observer' or 'Student' so staff and patients can identify the person's role at a glance.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Issue a visible observer badge"
        },
        {
          "detail": "File the affiliation agreement (if applicable), the confidentiality acknowledgment, dates observed, and any patient-decline notes.\n\nRecord: extern/observer placement packet filed",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "File the placement record"
        },
        {
          "detail": "Observer departs; badge returned; documentation filed.",
          "id": "s10",
          "kind": "step",
          "title": "Placement completed"
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Student extern, observer or job-shadow placement — A school, pre-dental student or high-schooler asks to observe or extern in the clinic.",
      "title": "Student extern, observer or job-shadow placement",
      "trigger": "A school, pre-dental student or high-schooler asks to observe or extern in the clinic",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "USCIS Form I-9, 8 CFR 274a.2 — reverification required no later than the expiration date of a List A or List C document",
          "source": "USCIS Form I-9, 8 CFR 274a.2 — reverification required no later than the expiration date of a List A or List C document",
          "url": "https://www.uscis.gov/i-9"
        },
        {
          "kind": "regulation",
          "label": "8 U.S.C. §1324a(b) / 8 CFR 274a — employer response obligations to a DHS/ICE Notice of Inspection (I-9 audit), including the three-business-day production window",
          "source": "8 U.S.C. §1324a(b) / 8 CFR 274a — employer response obligations to a DHS/ICE Notice of Inspection (I-9 audit), including the three-business-day production window",
          "url": "https://www.ecfr.gov/current/title-8/section-274a.2"
        },
        {
          "kind": "statute",
          "label": "California SB 1001 / Labor Code §1019.1 — restrictions on immigration-related unfair practices during reverification (no demand for more/different documents than required)",
          "source": "California SB 1001 / Labor Code §1019.1 — restrictions on immigration-related unfair practices during reverification (no demand for more/different documents than required)",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hro-021",
      "kind": "operational",
      "materials": [
        "Form I-9 (current edition)",
        "employee work-authorization document tracking log",
        "Notice of Inspection response checklist",
        "attorney/counsel referral contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Determine whether this is a routine reverification (a document is expiring) or a Notice of Inspection from DHS/ICE.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "expiry",
              "label": "An employee's work-authorization document is expiring"
            },
            {
              "goto": "s7",
              "id": "inspection",
              "label": "A Notice of Inspection has arrived"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "hr",
          "title": "Which event triggered this protocol?"
        },
        {
          "detail": "HR's document tracking log flags the employee whose List A or List C document is nearing its expiration date, generating a reminder well ahead of the deadline.\n\nWhy: Reverification must be complete no later than the expiration date — a missed deadline turns a paperwork task into a work-authorization gap.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Flag the upcoming expiration from the tracking log",
          "why": "Reverification must be complete no later than the expiration date — a missed deadline turns a paperwork task into a work-authorization gap."
        },
        {
          "detail": "HR notifies the employee in writing that reverification is required, naming only the document categories the employee may choose from — never demanding a specific document or more documentation than the form requires.\n\nWhy: Requesting specific or extra documents during reverification is itself a prohibited immigration-related unfair practice under state and federal law.\n\nRecord: reverification notice sent to employee, dated",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Notify the employee of the required reverification",
          "why": "Requesting specific or extra documents during reverification is itself a prohibited immigration-related unfair practice under state and federal law."
        },
        {
          "detail": "Confirm whether the employee produced acceptable renewed documentation before the deadline.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "renewed",
              "label": "Valid renewed document presented"
            },
            {
              "goto": "s11",
              "id": "not-renewed",
              "label": "No valid document by the deadline"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "hr",
          "title": "Did the employee present a valid new document before expiration?"
        },
        {
          "detail": "HR completes the reverification section of the current Form I-9 with the new document's information and re-files it in the employee's I-9 record.\n\nRecord: updated Form I-9 filed",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Complete Supplement B of Form I-9"
        },
        {
          "detail": "Reverification completed or inspection response delivered, with counsel involvement documented wherever required.",
          "id": "s6",
          "kind": "step",
          "title": "I-9 event closed out"
        },
        {
          "detail": "Practice owner routes the Notice of Inspection to employment/immigration counsel immediately upon receipt, before responding to DHS/ICE or altering any I-9 records.\n\nWhy: The response window is short (typically three business days to produce I-9s) and altering records after a notice arrives can itself be treated as obstruction — counsel review before any action is non-negotiable.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route the Notice of Inspection to counsel immediately.",
            "role": "immigration counsel",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Route the Notice of Inspection to counsel immediately",
          "why": "The response window is short (typically three business days to produce I-9s) and altering records after a notice arrives can itself be treated as obstruction — counsel review before any action is non-negotiable."
        },
        {
          "detail": "HR assembles the complete, unaltered set of I-9 forms and supporting documentation requested in the notice, under counsel's direction on scope and format.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Assemble the requested I-9 records"
        },
        {
          "detail": "Track the response deadline stated in the Notice of Inspection (commonly three business days) and confirm delivery to DHS/ICE within that window, coordinated through counsel. duration_min (4320) is a conservative flat 72-hour calendar-hour floor, not a business-day calculator — the actual notice deadline as stated by DHS/ICE governs whenever it falls later than the flat 72-hour mark.",
          "id": "s9",
          "kind": "timer",
          "role": "hr",
          "timer_seconds": 259200,
          "title": "Track the response deadline"
        },
        {
          "detail": "File a copy of the notice, the records produced, the delivery confirmation, and counsel's guidance memo.\n\nRecord: Notice of Inspection response packet filed",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the inspection response record"
        },
        {
          "detail": "Before suspending or terminating an employee for a failed reverification, HR escalates to the practice owner and outside employment counsel to confirm the timeline, any pending appeal or extension the employee may have, and that the action is applied consistently.\n\nWhy: Terminating on a work-authorization failure without legal review risks both an unlawful-discrimination claim if applied inconsistently and a continued-employment-of-unauthorized-worker violation if delayed too long — this is exactly the narrow band where licensed counsel review is required, not optional HR judgment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate a failed reverification to legal counsel before any adverse action.",
            "role": "employment counsel",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Escalate a failed reverification to legal counsel before any adverse action",
          "why": "Terminating on a work-authorization failure without legal review risks both an unlawful-discrimination claim if applied inconsistently and a continued-employment-of-unauthorized-worker violation if delayed too long — this is exactly the narrow band where licensed counsel review is required, not optional HR judgment."
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "I-9 reverification and immigration Notice of Inspection response — An employee's work authorization expires, or an I-9 inspection notice arrives.",
      "title": "I-9 reverification and immigration Notice of Inspection response",
      "trigger": "An employee's work authorization expires, or an I-9 inspection notice arrives",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code §432.3 — employers with 15+ employees must include the pay scale in job postings and provide it to current employees on request",
          "source": "California Labor Code §432.3 — employers with 15+ employees must include the pay scale in job postings and provide it to current employees on request",
          "url": "https://www.dir.ca.gov/dlse/"
        },
        {
          "kind": "statute",
          "label": "California Labor Code §1197.5 — equal pay and pay-history restrictions relevant to setting the disclosed range",
          "source": "California Labor Code §1197.5 — equal pay and pay-history restrictions relevant to setting the disclosed range",
          "url": "https://www.dir.ca.gov/dlse/"
        }
      ],
      "class": "employment-hr-policy",
      "department": "hr",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "hro-022",
      "kind": "operational",
      "materials": [
        "pay-scale worksheet by role",
        "job-posting template",
        "internal pay-equity notes"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "HR confirms current employee headcount meets or exceeds the state's threshold (15 or more employees, at least one based in the disclosure-requiring state) that triggers mandatory pay-scale disclosure.\n\nWhy: The obligation is headcount-triggered — a practice below the threshold may still choose to disclose voluntarily, but the mandatory workflow only applies once the threshold is met, and headcount can change between postings.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Confirm the practice meets the headcount threshold",
          "why": "The obligation is headcount-triggered — a practice below the threshold may still choose to disclose voluntarily, but the mandatory workflow only applies once the threshold is met, and headcount can change between postings."
        },
        {
          "detail": "Is this a new job posting or an existing-employee request?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "posting",
              "label": "New job posting"
            },
            {
              "goto": "s7",
              "id": "request",
              "label": "Current employee requests the pay scale for their role"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hr",
          "title": "Is this a new job posting or an existing-employee request?"
        },
        {
          "detail": "HR pulls the good-faith salary or hourly range for the posted role from the practice's pay-scale worksheet, set based on role, experience band, and market data.\n\nWhy: The disclosed range must be a real, good-faith range the practice is willing to pay — not a placeholder or artificially wide band, which regulators treat as a disguised non-disclosure.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Pull the pay-scale range from the worksheet",
          "why": "The disclosed range must be a real, good-faith range the practice is willing to pay — not a placeholder or artificially wide band, which regulators treat as a disguised non-disclosure."
        },
        {
          "detail": "Include the pay range directly in the job posting text (not behind a link or only available on request), on every platform where the job is advertised, including third-party job boards.\n\nWhy: Disclosure on only one platform while omitting it on others is a common gap — the obligation follows the posting, not just the primary channel.\n\nRecord: pay-scale text and posting URLs logged",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Insert the pay scale into the posting template",
          "why": "Disclosure on only one platform while omitting it on others is a common gap — the obligation follows the posting, not just the primary channel."
        },
        {
          "detail": "Practice owner confirms the disclosed range is accurate, currently affordable, and consistent with what is paid to existing employees in comparable roles before the posting is published.\n\nWhy: A disclosed range inconsistent with actual pay to incumbents in the same role is a pay-equity exposure that the disclosure requirement makes newly visible to applicants.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner reviews the range before the posting goes live.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner reviews the range before the posting goes live",
          "why": "A disclosed range inconsistent with actual pay to incumbents in the same role is a pay-equity exposure that the disclosure requirement makes newly visible to applicants."
        },
        {
          "detail": "Posting published with range included, or employee request fulfilled and logged.",
          "id": "s6",
          "kind": "step",
          "title": "Pay-scale disclosure obligation met"
        },
        {
          "detail": "HR provides the current pay scale for the employee's own position within the required timeframe, in writing.\n\nWhy: Current employees, not just applicants, have a standing right to request their own position's pay scale — this is a separate obligation from the posting requirement.\n\nRecord: date and method of pay-scale disclosure to the employee",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Provide the pay scale to the requesting employee",
          "why": "Current employees, not just applicants, have a standing right to request their own position's pay scale — this is a separate obligation from the posting requirement."
        }
      ],
      "subclass": "hr-hiring-onboarding-training-and-offboarding",
      "summary": "Pay-range disclosure in job postings and on applicant request — A job is posted, or an applicant or employee asks for the pay scale.",
      "title": "Pay-range disclosure in job postings and on applicant request",
      "trigger": "A job is posted, or an applicant or employee asks for the pay scale",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Community Water Fluoridation and school sealant program guidance",
          "source": "CDC Community Water Fluoridation and school sealant program guidance",
          "url": "https://www.cdc.gov/oral-health/"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "statute",
          "label": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "source": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 50,
      "frequency": "per-patient",
      "id": "hyg-001",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "explorer and mirror",
        "hand scalers and ultrasonic scaler",
        "prophy angle and polishing paste",
        "floss",
        "personal protective equipment"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the health-history update is current, note any new medications or conditions, and review findings from the last visit before seating begins.\n\nWhy: A missed medication change (e.g. a new anticoagulant) can change what instrumentation is safe to use today.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Review updated health history and prior chart notes",
          "why": "A missed medication change (e.g. a new anticoagulant) can change what instrumentation is safe to use today."
        },
        {
          "detail": "Screen probing depths and bleeding on probing at representative sites (or full six-point chart if due per hyg-004); note any sites of concern.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Perform periodontal screening"
        },
        {
          "detail": "Is the screening consistent with health/gingivitis, or does it suggest periodontitis?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "healthy-gingivitis",
              "label": "Consistent with health or gingivitis — proceed with prophylaxis"
            },
            {
              "goto": "s12",
              "id": "possible-periodontitis",
              "label": "New pocketing/bleeding pattern suggests periodontitis"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is the screening consistent with health/gingivitis, or does it suggest periodontitis?"
        },
        {
          "detail": "Use ultrasonic and hand instrumentation to debride all tooth surfaces, working systematically by quadrant.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Remove supra- and subgingival plaque and calculus"
        },
        {
          "detail": "Selective or full-mouth polish with an appropriate-grit paste, then floss all interproximal surfaces and check for residual calculus.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Polish and floss"
        },
        {
          "detail": "Is topical fluoride indicated today?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "fluoride-indicated",
              "label": "Moderate/high caries risk or patient preference — apply fluoride"
            },
            {
              "goto": "s8",
              "id": "not-indicated",
              "label": "Low risk, fluoride not indicated today"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is topical fluoride indicated today?"
        },
        {
          "detail": "Continue directly into hyg-005 (topical fluoride varnish application) before dismissing the patient.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Hand off to the fluoride varnish protocol"
        },
        {
          "detail": "Coach brushing/flossing technique on any missed or bleeding areas found today (full protocol in hyg-008 when a deeper conversation is needed).",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Provide individualized home-care instruction"
        },
        {
          "detail": "Brief the dentist per hyg-010 and hand off the chart for the exam before checkout.",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Signal the dentist for the periodic exam"
        },
        {
          "detail": "Document: procedures performed, periodontal screening result, fluoride applied or declined, home-care coaching given, and next recall interval, entered in the chart.",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Record the completed prophylaxis visit"
        },
        {
          "detail": "Recare visit complete",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Recare visit complete"
        },
        {
          "detail": "Complete a full six-point periodontal chart (hyg-004) and route the finding to the dentist exam rather than completing a routine prophylaxis today.\n\nWhy: A prophylaxis code is not appropriate once periodontitis is suspected; the visit shifts toward diagnosis and possible SRP planning.",
          "id": "s12",
          "kind": "step",
          "role": "hygienist",
          "title": "Flag for full periodontal charting and dentist diagnosis",
          "why": "A prophylaxis code is not appropriate once periodontitis is suspected; the visit shifts toward diagnosis and possible SRP planning."
        },
        {
          "detail": "The treating dentist personally reviews the new periodontal finding and confirms the diagnosis and treatment path before billing or treatment code changes.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the periodontal finding before treatment coding changes.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the periodontal finding before treatment coding changes"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Adult recare (prophylaxis) visit — assessment, debridement, polish, instruction — A healthy or gingivitis patient arrives for a scheduled cleaning.",
      "title": "Adult recare (prophylaxis) visit — assessment, debridement, polish, instruction",
      "trigger": "A healthy or gingivitis patient arrives for a scheduled cleaning",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "source": "HIPAA 45 CFR 164 (records, minimum necessary in referrals and records import)",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 75,
      "frequency": "per-patient",
      "id": "hyg-002",
      "kind": "clinical",
      "materials": [
        "health-history intake form",
        "periodontal probe",
        "full-mouth radiograph series or panoramic order",
        "intraoral camera (optional)",
        "caries-risk assessment form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the intake form is complete; review medications, allergies, and any medical conditions relevant to hygiene treatment.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Collect and review the health-history intake"
        },
        {
          "detail": "Are radiographs needed today?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "radiographs-needed",
              "label": "No current radiographs on file — take the indicated series"
            },
            {
              "goto": "s4",
              "id": "radiographs-on-file",
              "label": "Current radiographs already on file"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Are radiographs needed today?"
        },
        {
          "detail": "Expose a full-mouth series or panoramic plus bitewings as clinically indicated for a new patient, following ALARA principles.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Take the indicated radiographic series"
        },
        {
          "detail": "Chart probing depths, bleeding on probing, recession, mobility and furcations at six sites per tooth (see hyg-004 for the standalone protocol).\n\nWhy: Baseline perio data is required before any future comparison can show change over time.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Complete a full baseline six-point periodontal chart",
          "why": "Baseline perio data is required before any future comparison can show change over time."
        },
        {
          "detail": "Diet, fluoride exposure, saliva flow, prior caries history, and visible plaque, per practice caries-risk form.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Complete a caries-risk assessment"
        },
        {
          "detail": "Remove supra- and subgingival deposits to the extent appropriate for a first visit; heavy calculus may require a second debridement appointment before the dentist exam.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Perform initial debridement"
        },
        {
          "detail": "Selective polish and floss all accessible interproximal surfaces.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Polish and floss"
        },
        {
          "detail": "Are baseline intraoral photographs part of the practice's new-patient protocol?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "photos-yes",
              "label": "Take baseline intraoral photographs"
            },
            {
              "goto": "s10",
              "id": "photos-no",
              "label": "Photographs not part of today's protocol"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "hygienist",
          "title": "Are baseline intraoral photographs part of the practice's new-patient protocol?"
        },
        {
          "detail": "Take a standard series (e.g. full-face smile, retracted anterior, right/left buccal) for the chart record.",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Capture baseline intraoral photographs"
        },
        {
          "detail": "Summarize periodontal findings, caries risk, radiograph availability, and any patient concerns for the dentist's comprehensive exam (see hyg-010).",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Prepare the comprehensive-exam handoff to the dentist"
        },
        {
          "detail": "The treating dentist personally reviews the hygienist's baseline periodontal chart, caries-risk assessment and radiographs before finalizing them as the new-patient baseline of record.\n\nWhy: Baseline data drives every future comparison and treatment decision; the dentist must confirm it before it is locked in as the reference chart.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on baseline findings before the comprehensive exam.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on baseline findings before the comprehensive exam",
          "why": "Baseline data drives every future comparison and treatment decision; the dentist must confirm it before it is locked in as the reference chart."
        },
        {
          "detail": "Document: health history, perio chart, caries-risk level, radiographs taken, and photographs (if any), entered in the chart as the new-patient baseline.",
          "id": "s12",
          "kind": "step",
          "role": "hygienist",
          "title": "Record all baseline data collected"
        },
        {
          "detail": "Baseline data complete, ready for comprehensive dentist exam",
          "id": "s13",
          "kind": "step",
          "role": "hygienist",
          "title": "Baseline data complete, ready for comprehensive dentist exam"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "New patient hygiene visit with comprehensive data collection — A new adult patient is seen in the hygiene column first.",
      "title": "New patient hygiene visit with comprehensive data collection",
      "trigger": "A new adult patient is seen in the hygiene column first",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "statute",
          "label": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "source": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "hyg-003",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "ultrasonic scaler with subgingival tips",
        "local anesthetic supplies (if used)",
        "prior periodontal chart for comparison"
      ],
      "needs_ack_review": true,
      "outcomes": [
        "perio_interval_kept",
        "patient_reported_scale"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull up the last periodontal chart to know which sites were previously deep or bleeding, so today's probing can be compared directly.\n\nWhy: Periodontal maintenance is judged by change over time, not a single visit's numbers.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Review the prior periodontal chart before probing",
          "why": "Periodontal maintenance is judged by change over time, not a single visit's numbers."
        },
        {
          "detail": "Re-probe all six sites per tooth and record bleeding, suppuration, and mobility changes.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Chart current probing depths and bleeding on probing"
        },
        {
          "detail": "Is the disease stable compared to the prior chart?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "stable",
              "label": "Stable or improved — continue maintenance"
            },
            {
              "goto": "s11",
              "id": "progressing",
              "label": "New or worsening pocketing/bleeding found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is the disease stable compared to the prior chart?"
        },
        {
          "detail": "Debride biofilm and calculus at and below the gumline in all sites, with particular attention to any site still bleeding on probing.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Instrument all quadrants supra- and subgingivally"
        },
        {
          "detail": "Is local anesthesia needed for patient comfort during subgingival instrumentation?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-anesthesia",
              "label": "Not needed today"
            },
            {
              "goto": "s12",
              "id": "anesthesia-needed",
              "label": "Patient reports discomfort — administer local anesthetic"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is local anesthesia needed for patient comfort during subgingival instrumentation?"
        },
        {
          "detail": "Selective polish; irrigate deeper pockets as indicated per practice protocol.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Polish and irrigate"
        },
        {
          "detail": "Target coaching to the specific sites still bleeding or hard to reach, including interdental aid recommendations.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Reinforce site-specific home-care instruction"
        },
        {
          "detail": "Book the next periodontal maintenance visit at the interval matching current stability (typically 3–4 months) before the patient leaves.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm the maintenance interval"
        },
        {
          "detail": "Document: current perio chart, comparison to prior visit, anesthetic used (if any), and the confirmed next interval, entered in the chart.",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Record the maintenance visit"
        },
        {
          "detail": "Periodontal maintenance visit complete",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Periodontal maintenance visit complete"
        },
        {
          "detail": "The treating dentist personally reviews sites showing progression and decides whether localized re-treatment, a new SRP episode, or a specialist referral is needed before maintenance continues.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before returning to active therapy.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before returning to active therapy"
        },
        {
          "detail": "Administer topical or local anesthetic within the hygienist's licensed scope, or hand off to the dentist where required by state scope of practice.",
          "id": "s12",
          "kind": "step",
          "role": "hygienist",
          "title": "Administer local anesthetic per scope of practice"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Periodontal maintenance visit after active therapy — A patient with treated periodontitis returns on a 3–4 month interval.",
      "title": "Periodontal maintenance visit after active therapy",
      "trigger": "A patient with treated periodontitis returns on a 3–4 month interval",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "annual",
      "id": "hyg-004",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "perio charting form or software",
        "prior chart for comparison"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the date of the last full six-point chart; if it is over 12 months old, or new bleeding/pocketing was found today, a full chart is required now.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm the full chart is due"
        },
        {
          "detail": "The assistant enters probing depths, bleeding on probing, recession, mobility and furcation at each of six sites per tooth as the hygienist calls them out, confirming tooth numbers.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Assistant records as the hygienist calls out findings"
        },
        {
          "detail": "Mesiobuccal, mid-buccal, distobuccal, mesiolingual, mid-lingual, distolingual — probing depth and bleeding at each site, for every tooth present.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Probe and call out all six sites per tooth"
        },
        {
          "detail": "Flag any site with a clinically significant increase in probing depth (per dentist judgment — no numeric threshold is specified in the cited public-floor sources), new bleeding, or new furcation/mobility findings since the last chart.\n\nWhy: A single chart shows a snapshot; comparison to baseline is what reveals disease progression.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Compare the new chart to the prior baseline",
          "why": "A single chart shows a snapshot; comparison to baseline is what reveals disease progression."
        },
        {
          "detail": "Are there significant changes from baseline?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-change",
              "label": "No significant change — stable"
            },
            {
              "goto": "s8",
              "id": "significant-change",
              "label": "Significant new pocketing, bleeding, or mobility found"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "hygienist",
          "title": "Are there significant changes from baseline?"
        },
        {
          "detail": "Document: complete six-point chart, comparison notes to baseline, and any dentist sign-off, entered in the chart as the new periodontal baseline of record.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Record the full periodontal chart"
        },
        {
          "detail": "Periodontal charting complete",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Periodontal charting complete"
        },
        {
          "detail": "Bring the comparison directly to the dentist for a diagnosis review before checkout, rather than waiting for the next scheduled exam.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Flag the chart for the dentist's diagnosis before the patient leaves"
        },
        {
          "detail": "The treating dentist personally reviews the flagged chart and confirms the diagnosis, staging and grading before it enters a treatment plan.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the periodontal diagnosis.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the periodontal diagnosis"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Six-point periodontal charting with comparison to baseline — The annual perio chart is due, or bleeding or pocketing is found at a prophylaxis.",
      "title": "Six-point periodontal charting with comparison to baseline",
      "trigger": "The annual perio chart is due, or bleeding or pocketing is found at a prophylaxis",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Community Water Fluoridation and school sealant program guidance",
          "source": "CDC Community Water Fluoridation and school sealant program guidance",
          "url": "https://www.cdc.gov/oral-health/"
        },
        {
          "kind": "open_standard",
          "label": "ADA Topical Fluoride Clinical Practice Guideline + AAPD Silver Diamine Fluoride policy/guideline + AAPD Pit-and-Fissure Sealants policy — fluoride/sealant/SDF protocols only",
          "repaired": {
            "action": "reduce",
            "evidence": "'The ADA guideline offers recommendations for topical fluoride agents including mouthrinses, varnishes, gels, foams, and pastes'; AAPD SDF guidance: 'SDF is safe when used in adults and children in accordance with dosing and application criteria'; sealants guidance: 'Sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents.' (search results, ada.org/aapd.org).",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAPD evidence-based fluoride, sealant and silver diamine fluoride guidelines (openly published)",
              "url": null
            }
          },
          "source": "ADA, 'Topical Fluoride Clinical Practice Guideline' (ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline); AAPD, 'Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients' (aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf) and 'Use of Silver Diamine Fluoride for Dental Caries Management' guideline (aapd.org/media/Policies_Guidelines/G_SDF.pdf); AAPD Pit-and-Fissure Sealants policy (aapd.org/research/oral-health-policies--recommendations/pit_and_fissure_sealants/). Scope: hyg-005 (fluoride varnish), hyg-006 (sealants), hyg-007 (SDF) only — does NOT reach hyg-009 (dentin hypersensitivity assessment) or hyg-014 (dry-mouth/medication review), which are unrelated topics not addressed by these fluoride/sealant/SDF documents.",
          "url": "https://www.ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "hyg-005",
      "kind": "clinical",
      "materials": [
        "fluoride varnish (single-dose applicators)",
        "cotton rolls or air/water syringe for drying",
        "applicator brush"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Review the current caries-risk level in the chart and ask about any known allergy to rosin/colophony or other varnish ingredients before proceeding.\n\nWhy: Fluoride varnish commonly contains a rosin base; an allergy must be ruled out before application.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm caries risk level and check for allergy",
          "why": "Fluoride varnish commonly contains a rosin base; an allergy must be ruled out before application."
        },
        {
          "detail": "Is there a known allergy to rosin/colophony or other varnish ingredient?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-known-allergy",
              "label": "No known allergy — proceed to the caries-risk indication check"
            },
            {
              "goto": "s11",
              "id": "known-allergy",
              "label": "Known allergy identified — varnish is contraindicated, do not apply"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is there a known allergy to rosin/colophony or other varnish ingredient?"
        },
        {
          "detail": "Is fluoride varnish indicated today?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "indicated",
              "label": "Moderate/high risk or pediatric recall — offer fluoride"
            },
            {
              "goto": "s12",
              "id": "not-indicated",
              "label": "Low risk, not routinely indicated"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is fluoride varnish indicated today?"
        },
        {
          "detail": "Explain the benefit in plain language and confirm the patient (or parent/caregiver for a minor) agrees before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Offer fluoride and confirm consent"
        },
        {
          "detail": "Does the patient/caregiver accept fluoride today?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "accepts",
              "label": "Accepts fluoride application"
            },
            {
              "goto": "s11",
              "id": "declines",
              "label": "Declines — route to the decline/alternatives protocol"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "hygienist",
          "title": "Does the patient/caregiver accept fluoride today?"
        },
        {
          "detail": "Use cotton rolls or air-dry the teeth to be treated so the varnish sets on a dry surface.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate and dry the teeth"
        },
        {
          "detail": "Paint a thin layer of varnish onto all tooth surfaces using the applicator brush, working systematically by quadrant.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Apply fluoride varnish to all tooth surfaces"
        },
        {
          "detail": "Instruct the patient to avoid brushing and eating hard, hot, or crunchy foods for the practice-specified wait time (commonly several hours) and to eat only soft foods until then.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Give post-application instructions"
        },
        {
          "detail": "Document: caries risk level, allergy check result, and whether fluoride was applied or declined, entered in the chart.",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Record the fluoride application or decline"
        },
        {
          "detail": "Fluoride step complete",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Fluoride step complete"
        },
        {
          "detail": "Follow hyg-018 to document the decline and discuss any fluoride-free alternative the patient requests.",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Hand off to the decline-and-alternatives protocol"
        },
        {
          "detail": "Fluoride not indicated today",
          "id": "s12",
          "kind": "step",
          "role": "hygienist",
          "title": "Fluoride not indicated today"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Topical fluoride varnish application by risk level — Caries risk is moderate or high, or the patient is a child at a recall visit.",
      "title": "Topical fluoride varnish application by risk level",
      "trigger": "Caries risk is moderate or high, or the patient is a child at a recall visit",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Community Water Fluoridation and school sealant program guidance",
          "source": "CDC Community Water Fluoridation and school sealant program guidance",
          "url": "https://www.cdc.gov/oral-health/"
        },
        {
          "kind": "open_standard",
          "label": "ADA Topical Fluoride Clinical Practice Guideline + AAPD Silver Diamine Fluoride policy/guideline + AAPD Pit-and-Fissure Sealants policy — fluoride/sealant/SDF protocols only",
          "repaired": {
            "action": "reduce",
            "evidence": "'The ADA guideline offers recommendations for topical fluoride agents including mouthrinses, varnishes, gels, foams, and pastes'; AAPD SDF guidance: 'SDF is safe when used in adults and children in accordance with dosing and application criteria'; sealants guidance: 'Sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents.' (search results, ada.org/aapd.org).",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAPD evidence-based fluoride, sealant and silver diamine fluoride guidelines (openly published)",
              "url": null
            }
          },
          "source": "ADA, 'Topical Fluoride Clinical Practice Guideline' (ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline); AAPD, 'Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients' (aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf) and 'Use of Silver Diamine Fluoride for Dental Caries Management' guideline (aapd.org/media/Policies_Guidelines/G_SDF.pdf); AAPD Pit-and-Fissure Sealants policy (aapd.org/research/oral-health-policies--recommendations/pit_and_fissure_sealants/). Scope: hyg-005 (fluoride varnish), hyg-006 (sealants), hyg-007 (SDF) only — does NOT reach hyg-009 (dentin hypersensitivity assessment) or hyg-014 (dry-mouth/medication review), which are unrelated topics not addressed by these fluoride/sealant/SDF documents.",
          "url": "https://www.ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "hyg-006",
      "kind": "clinical",
      "materials": [
        "etchant",
        "sealant material and curing light",
        "cotton rolls or rubber dam for isolation",
        "explorer",
        "articulating paper"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Examine each molar/premolar for deep pits and fissures with no cavitation and no existing restoration; confirm with the dentist which teeth are indicated.\n\nWhy: A sealant placed over an undetected cavitated lesion traps decay rather than preventing it.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Assess tooth-by-tooth sealant candidacy",
          "why": "A sealant placed over an undetected cavitated lesion traps decay rather than preventing it."
        },
        {
          "detail": "Is the tooth a good sealant candidate?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "candidate",
              "label": "Deep grooves, no cavitation — proceed with sealant"
            },
            {
              "goto": "s10",
              "id": "not-candidate",
              "label": "Cavitation present or restoration already placed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the tooth a good sealant candidate?"
        },
        {
          "detail": "Confirm the patient or parent/caregiver understands and agrees to sealant placement before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent for sealant placement.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "hygienist",
          "title": "Confirm consent for sealant placement"
        },
        {
          "detail": "Clean the occlusal surface and isolate with cotton rolls or a rubber dam to keep the tooth completely dry through curing.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate and clean the tooth surface"
        },
        {
          "detail": "Apply etchant to the pits and fissures for the manufacturer-specified time, rinse thoroughly, and re-isolate to keep the surface dry.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Etch, rinse and re-dry"
        },
        {
          "detail": "Flow sealant material into the pits and fissures without voids, then light-cure per the manufacturer's instructions.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Apply and cure the sealant material"
        },
        {
          "detail": "Use articulating paper to check for high spots and adjust; run an explorer over the sealant to confirm full retention with no voids.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Check occlusion and retention"
        },
        {
          "detail": "Document: tooth number(s) sealed, material used, and retention check result, entered in the chart with a note to re-check at the next recall.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Record the sealant placement"
        },
        {
          "detail": "Sealant placement complete",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Sealant placement complete"
        },
        {
          "detail": "Sealant not indicated for this tooth",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Sealant not indicated for this tooth"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Pit-and-fissure sealant placement with isolation and retention check — A newly erupted or at-risk molar or premolar has deep grooves and no cavitation.",
      "title": "Pit-and-fissure sealant placement with isolation and retention check",
      "trigger": "A newly erupted or at-risk molar or premolar has deep grooves and no cavitation",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Topical Fluoride Clinical Practice Guideline + AAPD Silver Diamine Fluoride policy/guideline + AAPD Pit-and-Fissure Sealants policy — fluoride/sealant/SDF protocols only",
          "repaired": {
            "action": "reduce",
            "evidence": "'The ADA guideline offers recommendations for topical fluoride agents including mouthrinses, varnishes, gels, foams, and pastes'; AAPD SDF guidance: 'SDF is safe when used in adults and children in accordance with dosing and application criteria'; sealants guidance: 'Sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents.' (search results, ada.org/aapd.org).",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAPD evidence-based fluoride, sealant and silver diamine fluoride guidelines (openly published)",
              "url": null
            }
          },
          "source": "ADA, 'Topical Fluoride Clinical Practice Guideline' (ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline); AAPD, 'Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients' (aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf) and 'Use of Silver Diamine Fluoride for Dental Caries Management' guideline (aapd.org/media/Policies_Guidelines/G_SDF.pdf); AAPD Pit-and-Fissure Sealants policy (aapd.org/research/oral-health-policies--recommendations/pit_and_fissure_sealants/). Scope: hyg-005 (fluoride varnish), hyg-006 (sealants), hyg-007 (SDF) only — does NOT reach hyg-009 (dentin hypersensitivity assessment) or hyg-014 (dry-mouth/medication review), which are unrelated topics not addressed by these fluoride/sealant/SDF documents.",
          "url": "https://www.ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline"
        },
        {
          "kind": "statute",
          "label": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "source": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "hyg-007",
      "kind": "clinical",
      "materials": [
        "silver diamine fluoride solution",
        "petroleum jelly (to protect soft tissue)",
        "microbrush applicator",
        "written consent form",
        "cotton rolls for isolation"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "The dentist personally explains the permanent black staining of the treated lesion, the arrest-not-restoration nature of SDF, and alternatives, then obtains signed consent from the patient or parent/caregiver before any application.\n\nWhy: SDF causes permanent, visible black staining of the treated tooth structure; consent must be informed and documented before the irreversible cosmetic effect occurs.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain informed consent before applying silver diamine fluoride.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain informed consent before applying silver diamine fluoride",
          "why": "SDF causes permanent, visible black staining of the treated tooth structure; consent must be informed and documented before the irreversible cosmetic effect occurs."
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Silver diamine fluoride caries arrest with staining consent — A cavitated lesion in a patient where conventional restoration is not possible or not yet indicated.",
      "title": "Silver diamine fluoride caries arrest with staining consent",
      "trigger": "A cavitated lesion in a patient where conventional restoration is not possible or not yet indicated",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Community Water Fluoridation and school sealant program guidance",
          "source": "CDC Community Water Fluoridation and school sealant program guidance",
          "url": "https://www.cdc.gov/oral-health/"
        },
        {
          "kind": "generic",
          "label": "Generic brushing/flossing technique coaching — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic brushing/flossing technique coaching — generic functional equivalent"
          },
          "source": "Generic brushing/flossing technique coaching — Practice policy — no published authority governs this step."
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hyg-008",
      "kind": "clinical",
      "materials": [
        "disclosing solution or tablets (optional)",
        "model teeth and demonstration brush",
        "floss and interdental aid samples",
        "written home-care handout"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Observe or ask the patient to demonstrate brushing/flossing technique, and note plaque or bleeding scores from today's exam.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Assess the patient's current home-care technique"
        },
        {
          "detail": "Would disclosing solution help the patient see missed areas?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "use-disclosing",
              "label": "Use disclosing solution to show missed plaque"
            },
            {
              "goto": "s4",
              "id": "skip-disclosing",
              "label": "Skip disclosing solution, coach directly from exam findings"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Would disclosing solution help the patient see missed areas?"
        },
        {
          "detail": "Apply disclosing solution or tablets and show the patient, with a mirror, exactly which areas are consistently missed.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Apply disclosing solution and review missed areas together"
        },
        {
          "detail": "Pinpoint the specific problem — e.g. brushing pressure, angle at the gumline, or skipped interdental cleaning — rather than giving generic advice.\n\nWhy: Individualized coaching on the patient's actual gap changes behavior more reliably than a standard script repeated at every visit.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Identify the specific technique gaps",
          "why": "Individualized coaching on the patient's actual gap changes behavior more reliably than a standard script repeated at every visit."
        },
        {
          "detail": "Demonstrate proper brushing angle and interdental cleaning on a model or in the patient's own mouth with a mirror, then have the patient try it back.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Demonstrate correct technique"
        },
        {
          "detail": "Was a new appliance or prosthesis delivered today?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-appliance",
              "label": "No new appliance today"
            },
            {
              "goto": "s11",
              "id": "new-appliance",
              "label": "New appliance/prosthesis delivered today"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "hygienist",
          "title": "Was a new appliance or prosthesis delivered today?"
        },
        {
          "detail": "Recommend product categories by function (e.g. soft-bristle manual or powered brush, fluoride toothpaste, floss or interdental brush, antimicrobial rinse if indicated) without naming a specific commercial brand.\n\nWhy: Recommending by category keeps the guidance generic and functional rather than steering the patient to one vendor's product line.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Discuss home-care product categories generically",
          "why": "Recommending by category keeps the guidance generic and functional rather than steering the patient to one vendor's product line."
        },
        {
          "detail": "Give the patient (or caregiver) a written handout summarizing the technique demonstrated and the product categories discussed, for reference at home.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Provide a written home-care plan"
        },
        {
          "detail": "Document: plaque/bleeding scores, specific technique gap coached, and the home-care plan given, entered in the chart for comparison at the next recall.",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Record the home-care instruction"
        },
        {
          "detail": "Home-care instruction complete",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Home-care instruction complete"
        },
        {
          "detail": "Explain cleaning method, insertion/removal, and wear schedule specific to the appliance or prosthesis delivered (e.g. denture, retainer, night guard).",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Give appliance-specific care instructions"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Individualized oral hygiene instruction, home-care plan and generic product recommendation — Plaque or bleeding scores are above target, or a new appliance or prosthesis is delivered.",
      "title": "Individualized oral hygiene instruction, home-care plan and generic product recommendation",
      "trigger": "Plaque or bleeding scores are above target, or a new appliance or prosthesis is delivered",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Topical Fluoride Clinical Practice Guideline + AAPD Silver Diamine Fluoride policy/guideline + AAPD Pit-and-Fissure Sealants policy — fluoride/sealant/SDF protocols only",
          "repaired": {
            "action": "reduce",
            "evidence": "'The ADA guideline offers recommendations for topical fluoride agents including mouthrinses, varnishes, gels, foams, and pastes'; AAPD SDF guidance: 'SDF is safe when used in adults and children in accordance with dosing and application criteria'; sealants guidance: 'Sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents.' (search results, ada.org/aapd.org).",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAPD evidence-based fluoride, sealant and silver diamine fluoride guidelines (openly published)",
              "url": null
            }
          },
          "source": "ADA, 'Topical Fluoride Clinical Practice Guideline' (ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline); AAPD, 'Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients' (aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf) and 'Use of Silver Diamine Fluoride for Dental Caries Management' guideline (aapd.org/media/Policies_Guidelines/G_SDF.pdf); AAPD Pit-and-Fissure Sealants policy (aapd.org/research/oral-health-policies--recommendations/pit_and_fissure_sealants/). Scope: hyg-005 (fluoride varnish), hyg-006 (sealants), hyg-007 (SDF) only — does NOT reach hyg-009 (dentin hypersensitivity assessment) or hyg-014 (dry-mouth/medication review), which are unrelated topics not addressed by these fluoride/sealant/SDF documents.",
          "url": "https://www.ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "hyg-009",
      "kind": "clinical",
      "materials": [
        "air-water syringe",
        "cotton pellets",
        "desensitizing agent (e.g. potassium nitrate / fluoride varnish, per office formulary)",
        "explorer / periodontal probe",
        "cold-air or ice stimulus for testing"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ask onset, trigger (cold, air, sweet, biting), duration of the pain after the stimulus stops, and which teeth or side of the mouth.\n\nWhy: Sharp pain that stops quickly after the stimulus is removed is the classic dentin-hypersensitivity pattern; lingering or spontaneous pain points toward pulpal pathology instead.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Gather the sensitivity history",
          "why": "Sharp pain that stops quickly after the stimulus is removed is the classic dentin-hypersensitivity pattern; lingering or spontaneous pain points toward pulpal pathology instead."
        },
        {
          "detail": "Check for visible caries, cracked tooth, defective or leaking restoration, recent restorative work, exposed root surface/recession, erosion or abfraction wear, and recent whitening.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Rule out other causes before treating as hypersensitivity"
        },
        {
          "detail": "Decide whether findings point to hypersensitivity alone or to a condition needing the dentist's diagnosis.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "consistent",
              "label": "No caries, crack, defective restoration, or spontaneous/lingering pain found"
            },
            {
              "goto": "s10",
              "id": "flag-dentist",
              "label": "Caries, crack, leaking restoration, or lingering/spontaneous pain found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is this consistent with simple dentin hypersensitivity?"
        },
        {
          "detail": "Apply a brief cold-air or ice stimulus to the suspected tooth and compare the response with an adjacent unaffected tooth; note intensity and duration of the response.\n\nWhy: Confirms which tooth is actually responding and gives a baseline to compare after treatment.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Test the affected tooth or teeth with a controlled stimulus",
          "why": "Confirms which tooth is actually responding and gives a baseline to compare after treatment."
        },
        {
          "detail": "Dry and isolate the tooth, apply the office's desensitizing agent per the product's instructions for use, and allow the required contact time before rinsing.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "desensitizing agent (e.g. potassium nitrate / fluoride varnish, per office formulary)",
            "cotton pellets"
          ],
          "role": "hygienist",
          "title": "Select and apply an in-office desensitizing treatment"
        },
        {
          "detail": "Repeat the same cold-air stimulus used at gather_history/test_teeth and compare the response to the pre-treatment baseline.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Re-test the stimulus response"
        },
        {
          "detail": "Recommend a desensitizing (potassium-nitrate or stannous-fluoride type) toothpaste by generic active ingredient, soft-bristle brush, and gentle technique; caution against acidic-drink frequency if erosion contributed.\n\nWhy: In-office treatment is often temporary; a home routine sustains the effect between visits.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Give home-care instructions for ongoing management",
          "why": "In-office treatment is often temporary; a home routine sustains the effect between visits."
        },
        {
          "detail": "Document the affected tooth/teeth, pre- and post-treatment stimulus response, product used, home-care instructions given, and a note to re-check at the next recall visit.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Chart the finding, treatment, and follow-up plan"
        },
        {
          "detail": "Hypersensitivity managed chairside",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Hypersensitivity managed chairside"
        },
        {
          "detail": "Flag the tooth in the chart and hand the exam summary to the dentist during the exam handoff (see hyg-010) rather than treating as simple hypersensitivity.\n\nWhy: A cracked tooth or caries treated as hypersensitivity delays the real diagnosis.",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Route the finding to the dentist for diagnosis",
          "why": "A cracked tooth or caries treated as hypersensitivity delays the real diagnosis."
        },
        {
          "detail": "The dentist examines the flagged tooth, confirms or revises the differential, and signs off on the diagnosis and plan before it is charted as final.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before a clinical diagnosis is entered.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before a clinical diagnosis is entered"
        },
        {
          "detail": "Document the flagged tooth/site, the dentist's confirmed or revised differential diagnosis, and the resulting treatment plan or specialist referral, entered in the chart.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Chart the flagged finding and the dentist's diagnosis"
        },
        {
          "detail": "Referred for dentist diagnosis and treatment",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Referred for dentist diagnosis and treatment"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Dentin hypersensitivity assessment and desensitizing treatment — A patient reports cold or air sensitivity without caries or cracks.",
      "title": "Dentin hypersensitivity assessment and desensitizing treatment",
      "trigger": "A patient reports cold or air sensitivity without caries or cracks",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "Structured clinical handoff (one-minute summary) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Structured clinical handoff (one-minute summary) — generic functional equivalent"
          },
          "source": "Structured clinical handoff (one-minute summary) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 3,
      "frequency": "per-patient",
      "id": "hyg-010",
      "kind": "clinical",
      "materials": [
        "chart/PMS screen open to the visit note",
        "radiographs pulled up",
        "intraoral photos if taken"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Mentally (or on a sticky note) order the findings: perio status change, new or existing caries risk areas, restoration concerns, soft-tissue findings, and any patient-reported symptoms.\n\nWhy: A dentist walking room to room needs the summary front-loaded with what changed, not a chronological retelling of the whole appointment.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Prepare the one-minute findings summary before calling the dentist",
          "why": "A dentist walking room to room needs the summary front-loaded with what changed, not a chronological retelling of the whole appointment."
        },
        {
          "detail": "Radiographs for the visit (or most recent set) displayed on screen; any intraoral photos taken during the visit queued for review.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm radiographs and photos are pulled up and current"
        },
        {
          "detail": "Use the practice's standard signal (intercom, light system, or verbal call) once radiographs and summary are ready — not before.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Call or signal the dentist that the room is ready for exam"
        },
        {
          "detail": "State: periodontal status and any change from baseline, caries risk areas or suspicious spots, restoration/appliance concerns, soft-tissue findings, and anything the patient specifically asked about.\n\nWhy: A consistent order means the dentist never has to ask 'anything else?' and risk a missed finding.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Deliver the structured one-minute summary at chairside",
          "why": "A consistent order means the dentist never has to ask 'anything else?' and risk a missed finding."
        },
        {
          "detail": "Cross-check the verbal summary against the displayed radiographs and prior visit notes before beginning the physical exam.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews radiographs, photos, and chart alongside the verbal summary"
        },
        {
          "detail": "Complete the clinical exam, confirm or add to the hygienist's findings, and discuss any diagnosis or treatment recommendation with the patient chairside.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the periodic oral exam"
        },
        {
          "detail": "Decide whether the exam can proceed with hygienist alone or needs assistant support (charting, photos, or prepping for a same-day procedure).",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-support",
              "label": "Hygienist supports the exam directly; no assistant needed"
            },
            {
              "goto": "s10",
              "id": "assistant-needed",
              "label": "Assistant support needed for charting, photos, or a same-day finding"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is an assistant needed to support the exam or a same-day finding?"
        },
        {
          "detail": "Record the dentist's diagnosis, any treatment recommended, and the recall interval agreed at the exam.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Chart the exam outcome and any dentist instructions"
        },
        {
          "detail": "Exam handoff and dentist exam complete",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Exam handoff and dentist exam complete"
        },
        {
          "detail": "Tell the assistant which support is needed (charting under dictation, photos, or prep for a same-day treatment per hyg-015) and hand off the relevant chart screen.",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Notify the assistant and hand off supporting tasks"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Hygiene-to-dentist exam handoff (one-minute findings summary, radiographs ready) — The hygienist finishes and calls the dentist for the periodic exam.",
      "title": "Hygiene-to-dentist exam handoff (one-minute findings summary, radiographs ready)",
      "trigger": "The hygienist finishes and calls the dentist for the periodic exam",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "source": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1900.&lawCode=BPC"
        },
        {
          "kind": "generic",
          "label": "Two-column assisted hygiene staffing model — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Two-column assisted hygiene staffing model — generic functional equivalent"
          },
          "source": "Two-column assisted hygiene staffing model — Practice policy — no published authority governs this step."
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "daily",
      "id": "hyg-011",
      "kind": "clinical",
      "materials": [
        "two operatory setups",
        "assistant task list/timer",
        "PMS schedule showing both columns"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "assistant",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Review which tasks (polishing, coronal debridement steps, radiographs, setup/breakdown) the assigned assistant is licensed or permitted to perform in this state; anything outside scope stays with the hygienist.\n\nWhy: Assisted hygiene only saves time on tasks the assistant is legally permitted to do — assigning outside scope is a compliance risk, not an efficiency gain.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the assistant's tasks are within state scope of practice before the day starts.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm the assistant's tasks are within state scope of practice before the day starts",
          "why": "Assisted hygiene only saves time on tasks the assistant is legally permitted to do — assigning outside scope is a compliance risk, not an efficiency gain."
        },
        {
          "detail": "Seat the patient, update health history, take radiographs if due and within scope, and begin any permitted preliminary steps.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Assistant seats and preps Room A while hygienist is in Room B"
        },
        {
          "detail": "Perform assessment, debridement, and any task outside the assistant's scope while Room A is being prepped.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist actively treats the patient in Room B"
        },
        {
          "detail": "Check whether the assistant has finished prep in Room A before finishing up in Room B.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "ready",
              "label": "Room A prep is complete and patient is ready"
            },
            {
              "goto": "s11",
              "id": "not-ready",
              "label": "Room A prep is still in progress"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is Room A ready for the hygienist to move over?"
        },
        {
          "detail": "Give a 15-second summary: patient status, any findings from radiographs or health-history update, and readiness for the hygienist to begin.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Assistant briefs the hygienist on Room A before the switch"
        },
        {
          "detail": "Perform assessment and debridement while the assistant preps or breaks down Room B for the next patient.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist treats the patient in Room A"
        },
        {
          "detail": "Clean and set up Room B per infection-control protocol and pull the next patient's chart while Room A is active.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Assistant breaks down Room B and preps for the next patient"
        },
        {
          "detail": "Watch both columns for drift and adjust check-in timing or notify hyg-016 (running behind) if either room falls more than 10 minutes behind.",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Scheduler monitors the two-column pace against the day's schedule"
        },
        {
          "detail": "Complete each patient's chart note before or immediately after moving rooms so findings are not mixed up between the two columns.",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Chart findings and treatment separately for each room's patient"
        },
        {
          "detail": "Assisted two-column hygiene block complete",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Assisted two-column hygiene block complete"
        },
        {
          "detail": "Use home-care instruction or additional charting time in Room B rather than standing idle while Room A finishes prep.",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Extend polishing/instruction time in Room B"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Assisted hygiene (two-column) flow — The practice runs assisted hygiene with an assistant supporting two hygiene rooms.",
      "title": "Assisted hygiene (two-column) flow",
      "trigger": "The practice runs assisted hygiene with an assistant supporting two hygiene rooms",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "public_domain",
          "label": "CDC Community Water Fluoridation and school sealant program guidance",
          "source": "CDC Community Water Fluoridation and school sealant program guidance",
          "url": "https://www.cdc.gov/oral-health/"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "hyg-012",
      "kind": "clinical",
      "materials": [
        "risk-assessment note in chart",
        "recall scheduling screen"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "front-desk",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Check the chart's current caries-risk (low/moderate/high) and periodontal status/stability from today's visit and the six-point chart if updated (hyg-004).\n\nWhy: The interval should follow documented risk, not a default 6-month habit.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Review the patient's documented caries and periodontal risk category",
          "why": "The interval should follow documented risk, not a default 6-month habit."
        },
        {
          "detail": "Choose the interval band appropriate to the patient's risk and stability.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "low-risk",
              "label": "Low caries risk, periodontally healthy/stable — 6-month interval"
            },
            {
              "goto": "s3",
              "id": "moderate-risk",
              "label": "Moderate risk or early perio changes — 4-month interval"
            },
            {
              "goto": "s3",
              "id": "high-risk",
              "label": "High caries risk or active perio maintenance — 3-month interval"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Select the recall interval that matches risk"
        },
        {
          "detail": "State the interval and the specific reason (e.g. 'because of the bleeding we found today, we'd like to see you in 3 months') before handing off to book.\n\nWhy: A patient who understands the reason is more likely to keep the appointment than one who is just told a date.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Tell the patient the recommended interval and why",
          "why": "A patient who understands the reason is more likely to keep the appointment than one who is just told a date."
        },
        {
          "detail": "Give the front desk/scheduler the exact interval and any provider preference so the appointment is booked before the patient reaches checkout.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Hand the interval off to front desk or scheduler for same-visit booking"
        },
        {
          "detail": "Confirm whether a same-visit booking succeeded or the patient needs a follow-up contact.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "booked-now",
              "label": "Appointment booked before patient left the office"
            },
            {
              "goto": "s8",
              "id": "book-later",
              "label": "Patient could not book today — needs a follow-up call/text/email"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "scheduler",
          "title": "Was the recall booked before the patient left?"
        },
        {
          "detail": "Document the risk category used, interval selected, and whether the appointment was booked same-visit or queued for follow-up.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Record the recall interval and booking status in the chart"
        },
        {
          "detail": "Recall interval set and booking in progress or complete",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Recall interval set and booking in progress or complete"
        },
        {
          "detail": "Add the patient to the recall follow-up list with the target interval window so outreach happens before the window closes.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Queue a follow-up contact to book the recall"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Setting the recall interval to match risk before the patient leaves — The hygiene visit is complete; the interval must match risk and be booked at checkout.",
      "title": "Setting the recall interval to match risk before the patient leaves",
      "trigger": "The hygiene visit is complete; the interval must match risk and be booked at checkout",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "USPHS tobacco cessation guideline (public domain)",
          "source": "USPHS tobacco cessation guideline (public domain)",
          "url": "https://www.ncbi.nlm.nih.gov/books/NBK63947/"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "hyg-013",
      "kind": "clinical",
      "materials": [
        "cessation referral handout/quitline card",
        "chart tobacco-use field"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ask directly: current use, product type (cigarette, smokeless, vape/e-cigarette), and frequency.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Screen for current tobacco or vaping use during health history review"
        },
        {
          "detail": "Does the patient currently use tobacco or vape products?",
          "forks": [
            {
              "goto": "s10",
              "id": "no-use",
              "label": "No current use reported"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "current-use",
              "label": "Current use reported"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Does the patient currently use tobacco or vape products?"
        },
        {
          "detail": "Ask a single open question: 'Have you thought about cutting back or quitting?' Note the response without pressing further.\n\nWhy: The brief-intervention model asks and advises rather than debating — matching effort to a hygiene-visit time slot.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Ask about readiness to quit",
          "why": "The brief-intervention model asks and advises rather than debating — matching effort to a hygiene-visit time slot."
        },
        {
          "detail": "State plainly the connection to gum disease, staining, delayed healing, and oral cancer risk, and offer a referral regardless of stated readiness.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Advise on the oral-health link and offer help"
        },
        {
          "detail": "Is the patient willing to accept a referral today?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "accepts",
              "label": "Patient accepts a quitline/cessation referral"
            },
            {
              "goto": "s11",
              "id": "declines",
              "label": "Patient declines a referral today"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is the patient willing to accept a referral today?"
        },
        {
          "detail": "Hand out or note the public cessation quitline/resource; do not name a specific commercial cessation product or program.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "cessation referral handout/quitline card"
          ],
          "role": "hygienist",
          "title": "Give the cessation referral resource"
        },
        {
          "detail": "Note any leukoplakia, staining, or soft-tissue lesion for the dentist to specifically examine during the periodic exam (see hyg-010 handoff).\n\nWhy: Tobacco and vaping use raises oral-cancer screening priority for the exam that follows.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Flag tobacco/vaping-related oral findings for the dentist's exam",
          "why": "Tobacco and vaping use raises oral-cancer screening priority for the exam that follows."
        },
        {
          "detail": "Document use status, brief-intervention advice given, referral offered/accepted/declined, and any soft-tissue finding flagged.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Chart the screening, advice given, and outcome"
        },
        {
          "detail": "Brief cessation intervention complete",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Brief cessation intervention complete"
        },
        {
          "detail": "No current tobacco/vaping use — no intervention needed",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "No current tobacco/vaping use — no intervention needed"
        },
        {
          "detail": "Document that the patient was advised and declined; state the offer stands at future visits.",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Note the decline respectfully and leave the door open"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Tobacco and vaping brief cessation intervention and referral — A patient reports current tobacco or vaping use.",
      "title": "Tobacco and vaping brief cessation intervention and referral",
      "trigger": "A patient reports current tobacco or vaping use",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Topical Fluoride Clinical Practice Guideline + AAPD Silver Diamine Fluoride policy/guideline + AAPD Pit-and-Fissure Sealants policy — fluoride/sealant/SDF protocols only",
          "repaired": {
            "action": "reduce",
            "evidence": "'The ADA guideline offers recommendations for topical fluoride agents including mouthrinses, varnishes, gels, foams, and pastes'; AAPD SDF guidance: 'SDF is safe when used in adults and children in accordance with dosing and application criteria'; sealants guidance: 'Sealants are effective in preventing and arresting pit-and-fissure occlusal carious lesions of primary and permanent molars in children and adolescents.' (search results, ada.org/aapd.org).",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAPD evidence-based fluoride, sealant and silver diamine fluoride guidelines (openly published)",
              "url": null
            }
          },
          "source": "ADA, 'Topical Fluoride Clinical Practice Guideline' (ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline); AAPD, 'Policy on the Use of Silver Diamine Fluoride for Pediatric Dental Patients' (aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf) and 'Use of Silver Diamine Fluoride for Dental Caries Management' guideline (aapd.org/media/Policies_Guidelines/G_SDF.pdf); AAPD Pit-and-Fissure Sealants policy (aapd.org/research/oral-health-policies--recommendations/pit_and_fissure_sealants/). Scope: hyg-005 (fluoride varnish), hyg-006 (sealants), hyg-007 (SDF) only — does NOT reach hyg-009 (dentin hypersensitivity assessment) or hyg-014 (dry-mouth/medication review), which are unrelated topics not addressed by these fluoride/sealant/SDF documents.",
          "url": "https://www.ada.org/resources/research/science/evidence-based-dental-research/topical-fluoride-clinical-practice-guideline"
        },
        {
          "kind": "generic",
          "label": "Xerostomia risk from polypharmacy — generic clinical functional equivalent",
          "source": "Xerostomia risk from polypharmacy — generic clinical functional equivalent"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "hyg-014",
      "kind": "clinical",
      "materials": [
        "updated medication list",
        "saliva substitute/stimulant samples or handout",
        "fluoride home-care product recommendation sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Ask about subjective dryness, difficulty swallowing dry foods, need to sip water frequently, and count current medications from the updated health history.\n\nWhy: Xerogenic effect often comes from medication burden as a whole, not one drug — polypharmacy itself is a risk signal.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Screen for dry-mouth symptoms and medication load",
          "why": "Xerogenic effect often comes from medication burden as a whole, not one drug — polypharmacy itself is a risk signal."
        },
        {
          "detail": "Look for thick/ropy or minimal saliva pooling, dry/cracked oral mucosa or lips, increased plaque or new/atypical caries pattern (especially cervical/root surfaces).",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Check clinical signs of reduced saliva"
        },
        {
          "detail": "Are symptoms and/or signs consistent with clinically significant xerostomia?",
          "forks": [
            {
              "goto": "s9",
              "id": "not-significant",
              "label": "Mild or no signs — routine monitoring only"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "significant",
              "label": "Clear symptoms and/or clinical signs present"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Are symptoms and/or signs consistent with clinically significant xerostomia?"
        },
        {
          "detail": "The dentist reviews the medication list and clinical findings, confirms the diagnosis, and determines whether a medical-provider consult is warranted before a management plan is finalized.\n\nWhy: Medication-related diagnoses and any recommendation touching a patient's medical regimen need licensed review before the plan is finalized — never auto-generated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews medication list and confirms the xerostomia diagnosis.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews medication list and confirms the xerostomia diagnosis",
          "why": "Medication-related diagnoses and any recommendation touching a patient's medical regimen need licensed review before the plan is finalized — never auto-generated."
        },
        {
          "detail": "Does this need a consult with the patient's physician/pharmacist?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-consult",
              "label": "No medical consult needed — manage in-office"
            },
            {
              "goto": "s10",
              "id": "needs-consult",
              "label": "Medication complexity warrants a physician/pharmacist consult"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does this need a consult with the patient's physician/pharmacist?"
        },
        {
          "detail": "Recommend increased fluoride exposure (varnish/home fluoride), saliva substitutes or stimulants by generic ingredient type, frequent water sipping, avoiding alcohol-containing mouthrinse, and shortening the recall interval for caries monitoring.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "saliva substitute/stimulant samples or handout",
            "fluoride home-care product recommendation sheet"
          ],
          "role": "hygienist",
          "title": "Build the in-office management plan"
        },
        {
          "detail": "Document symptoms, clinical signs, dentist's diagnosis and sign-off, any consult routed, and the home-care/recall plan given to the patient.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Chart the assessment, dentist sign-off, and management plan"
        },
        {
          "detail": "Xerostomia management plan in place",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Xerostomia management plan in place"
        },
        {
          "detail": "No significant xerostomia — routine monitoring only",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "No significant xerostomia — routine monitoring only"
        },
        {
          "detail": "The dentist drafts the clinical consult content noting the oral findings and asking whether an alternative medication or dosing adjustment is appropriate, then front desk transmits the records-release-consented request — the dental team never changes a medical prescription itself.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Draft and route a consult request to the patient's physician or pharmacist"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Dry-mouth assessment, medication review and management plan — A patient reports dry mouth or takes multiple xerogenic medications.",
      "title": "Dry-mouth assessment, medication review and management plan",
      "trigger": "A patient reports dry mouth or takes multiple xerogenic medications",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "source": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1900.&lawCode=BPC"
        },
        {
          "kind": "generic",
          "label": "Same-day treatment conversion from hygiene finding — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Same-day treatment conversion from hygiene finding — generic functional equivalent"
          },
          "source": "Same-day treatment conversion from hygiene finding — Practice policy — no published authority governs this step."
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "hyg-015",
      "kind": "clinical",
      "materials": [
        "treatment fee estimate tool",
        "consent form for the procedure",
        "open-column schedule view"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist",
        "scheduler",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the finding, the proposed procedure, and whether it is a candidate for same-day treatment (e.g. limited restoration vs. a case needing a full treatment-planning visit).",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist diagnoses a treatment need during the hygiene exam"
        },
        {
          "detail": "Check the day's schedule for an open or convertible operatory slot with the dentist available.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "available",
              "label": "Doctor chair time is available now"
            },
            {
              "goto": "s11",
              "id": "not-available",
              "label": "No chair time available today"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "scheduler",
          "title": "Is doctor chair time available right now?"
        },
        {
          "detail": "Pull the procedure fee, check insurance benefits/eligibility if available, and prepare a same-visit estimate for the patient.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Prepare a same-day fee estimate"
        },
        {
          "detail": "Explain the finding, the recommended treatment, the fee estimate, and the option to do it today versus scheduling separately.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Present the diagnosis, treatment, and estimate to the patient"
        },
        {
          "detail": "Does the patient want to proceed with same-day treatment?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "accepts",
              "label": "Patient wants to proceed with treatment today"
            },
            {
              "goto": "s11",
              "id": "declines",
              "label": "Patient wants to schedule for another day"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient want to proceed with same-day treatment?"
        },
        {
          "detail": "Obtain and record the patient's informed consent for the specific procedure before any treatment begins — never treat on an assumed yes.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent before same-day treatment begins.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent before same-day treatment begins"
        },
        {
          "detail": "Wrap up the hygiene portion, hand the room and chart to the assistant for treatment setup, and reset the hygiene column with the scheduler's help.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist hands the room off to the dentist/assistant for treatment"
        },
        {
          "detail": "Update the schedule to reflect the added chair time, and notify any patients affected by the resulting shift (see hyg-016 if this causes hygiene to run behind).",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Scheduler adjusts the day's schedule around the conversion"
        },
        {
          "detail": "Document signed consent, fee estimate presented, and the resulting schedule adjustment in the chart and day sheet.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Record the consent, fee estimate, and schedule change"
        },
        {
          "detail": "Same-day treatment converted and scheduled",
          "id": "s10",
          "kind": "step",
          "role": "scheduler",
          "title": "Same-day treatment converted and scheduled"
        },
        {
          "detail": "Route the diagnosis and proposed treatment to the treatment coordinator to present the plan and book the next available appropriate slot.",
          "id": "s11",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to the treatment coordinator to schedule a future visit"
        },
        {
          "detail": "Treatment scheduled for a future visit instead",
          "id": "s12",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Treatment scheduled for a future visit instead"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Same-day doctor treatment from a hygiene finding — The dentist diagnoses during the hygiene exam and doctor chair time is available.",
      "title": "Same-day doctor treatment from a hygiene finding",
      "trigger": "The dentist diagnoses during the hygiene exam and doctor chair time is available",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "source": "State hygiene scope of practice (California B&P §§1900–1966; RDH/RDHAP)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1900.&lawCode=BPC"
        },
        {
          "kind": "generic",
          "label": "Schedule-recovery triage for a delayed clinical column — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Schedule-recovery triage for a delayed clinical column — generic functional equivalent"
          },
          "source": "Schedule-recovery triage for a delayed clinical column — Practice policy — no published authority governs this step."
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hyg-016",
      "kind": "clinical",
      "materials": [
        "day sheet/schedule view",
        "patient contact info for delay notification"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Compare actual current time against the scheduled start time for the current patient; confirm the gap has reached the 15-minute threshold.\n\nWhy: Catching the delay at 15 minutes gives room to recover before it compounds through the rest of the day.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Recognize the column is 15+ minutes behind",
          "why": "Catching the delay at 15 minutes gives room to recover before it compounds through the rest of the day."
        },
        {
          "detail": "Note whether the delay came from a complex case, a late patient arrival, a same-day treatment conversion (hyg-015), or an equipment/room issue.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Identify the cause of the delay"
        },
        {
          "detail": "Tell front desk how far behind the column is and a realistic estimate for when it will catch up.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Notify front desk of the delay and expected recovery time"
        },
        {
          "detail": "Are patients waiting or about to arrive who need to be told?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "notify-needed",
              "label": "A patient is waiting in the reception area or about to arrive"
            },
            {
              "goto": "s6",
              "id": "no-notify-needed",
              "label": "No patient currently waiting or about to arrive"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "Are patients waiting or about to arrive who need to be told?"
        },
        {
          "detail": "Let the patient know the estimated wait, offer water/reading material, and thank them for their patience.\n\nWhy: An informed wait is tolerated far better than an unexplained one.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Inform the waiting patient of the delay",
          "why": "An informed wait is tolerated far better than an unexplained one."
        },
        {
          "detail": "Shorten optional discussion time, defer non-urgent home-care instruction to a handout, and prioritize the clinical assessment and debridement itself.\n\nWhy: Recovery works by protecting the clinical core of each remaining visit, not by rushing it.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Trim non-essential tasks from the remaining visits to recover time",
          "why": "Recovery works by protecting the clinical core of each remaining visit, not by rushing it."
        },
        {
          "detail": "Will the column recover, or does it need dentist/scheduler intervention?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "will-recover",
              "label": "Trimming non-essential tasks is enough to recover"
            },
            {
              "goto": "s10",
              "id": "needs-intervention",
              "label": "Delay is severe enough to need a rescheduled or shortened later appointment"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "hygienist",
          "title": "Will the column recover, or does it need dentist/scheduler intervention?"
        },
        {
          "detail": "Note the cause, minutes lost, and what was done to recover, for the weekly hygiene metrics review (hyg-017).",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Log the delay, cause, and recovery action taken"
        },
        {
          "detail": "Column recovery action taken and logged",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Column recovery action taken and logged"
        },
        {
          "detail": "Notify the dentist of the ongoing delay and work with the scheduler to shorten, move, or reschedule a later appointment as needed.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Escalate to the dentist and scheduler for a schedule adjustment"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Hygiene running behind schedule — The hygiene column is 15 minutes behind.",
      "title": "Hygiene running behind schedule",
      "trigger": "The hygiene column is 15 minutes behind",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "No regulatory authority governs internal hygiene productivity/business metrics — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No regulatory authority governs internal hygiene productivity/business metrics — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The DHBC lawsregs page indexes Business and Professions Code §§1900–1966.6 and 16 CCR provisions covering RDH/RDHAP/RDHEF licensure, scope of practice, and permitted procedures — it contains no content on reappointment rate, periodontal-charting percentage, fluoride-treatment percentage, or production-per-hour as business metrics. Searched the DHBC statute index and found nothing addressing practice KPI tracking or reporting cadence in any form.",
            "ticket": "PROT-017",
            "was": {
              "source": "Dental Hygiene Board of California (DHBC) — regulates RDH, RDHAP, RDHEF under B&P §§1900–1967.4 and 16 CCR",
              "url": "https://dhbc.ca.gov/lawsregs/index.shtml"
            }
          },
          "source": "No regulatory authority governs internal hygiene productivity/business metrics — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Generic hygiene productivity metric definitions (reappointment %, perio %, fluoride %, production/hour) — standard practice-management reporting, not tied to a vendor — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic hygiene productivity metric definitions (reappointment %, perio %, fluoride %, production/hour) — standard practice-management reporting, not tied to a vendor"
          },
          "source": "Generic hygiene productivity metric definitions (reappointment %, perio %, fluoride %, production/hour) — standard practice-management reporting, not tied to a vendor — Practice policy — no published authority governs this step."
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "weekly",
      "id": "hyg-017",
      "kind": "clinical",
      "materials": [
        "practice management system report export",
        "hygiene metrics tracking sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "At the end of each hygiene day, the hygienist records patients seen, reappointment outcome, perio maintenance vs. prophy split, fluoride offered/accepted, and chair-hours used.\n\nWhy: Weekly numbers are only as good as the daily capture — retroactive reconstruction from the schedule loses the reappointment and fluoride-offer detail.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist logs daily hygiene tally",
          "why": "Weekly numbers are only as good as the daily capture — retroactive reconstruction from the schedule loses the reappointment and fluoride-offer detail."
        },
        {
          "detail": "Pull the week's daily tallies and the practice management system's production report; compute reappointment %, perio %, fluoride %, and production per hygiene hour.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Office manager compiles the weekly hygiene metrics report"
        },
        {
          "detail": "Are any metrics below the practice's target threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "below-target",
              "label": "One or more metrics below target"
            },
            {
              "goto": "s7",
              "id": "on-target",
              "label": "All metrics at or above target"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are any metrics below the practice's target threshold?"
        },
        {
          "detail": "Check whether the shortfall is scheduling (gaps, no-shows), clinical (fluoride not being offered, perio recall not flagged), or a specific hygienist's day; note the pattern.\n\nWhy: A single averaged number hides whether the fix is a schedule template change or a coaching conversation.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the likely root cause for each below-target metric",
          "why": "A single averaged number hides whether the fix is a schedule template change or a coaching conversation."
        },
        {
          "detail": "Write one to two concrete actions (e.g., 'reappoint at checkout, not by phone later', 'offer fluoride to every moderate/high-risk adult') and who owns each.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft a short coaching or process action for the coming week"
        },
        {
          "detail": "Office manager sends the compiled report with root causes and action items to the practice owner for visibility before the next huddle.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the metrics report and action plan to the practice owner"
        },
        {
          "detail": "Weekly hygiene metrics report (aggregate numbers only) filed in the practice management system's reporting archive or shared drive, dated.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "File the weekly hygiene metrics report"
        },
        {
          "detail": "Weekly hygiene metrics review complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Weekly hygiene metrics review complete"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Hygiene metrics (reappointment %, perio %, fluoride %, production per hour) — Daily tally, weekly review.",
      "title": "Hygiene metrics (reappointment %, perio %, fluoride %, production per hour)",
      "trigger": "Daily tally, weekly review",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/AAPD evidence-based fluoride and sealant guidelines (openly published)",
          "source": "ADA/AAPD evidence-based fluoride and sealant guidelines (openly published)",
          "url": "https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research"
        },
        {
          "kind": "public_domain",
          "label": "CDC Community Water Fluoridation and school sealant program guidance",
          "source": "CDC Community Water Fluoridation and school sealant program guidance",
          "url": "https://www.cdc.gov/oral-health/"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "hyg-018",
      "kind": "clinical",
      "materials": [
        "informed refusal form",
        "biocompatible/alternative product information sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Explain the recommendation in plain language, tied to the patient's caries risk level, per ADA/AAPD guidance — what it does, how it is applied, and expected benefit.\n\nWhy: Refusal decisions are more informed, and the record more defensible, when the recommendation and its basis were actually explained first.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Present the evidence-based fluoride or sealant recommendation",
          "why": "Refusal decisions are more informed, and the record more defensible, when the recommendation and its basis were actually explained first."
        },
        {
          "detail": "Does the patient or parent accept the recommendation?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "accepts",
              "label": "Accepts fluoride/sealant as recommended"
            },
            {
              "goto": "s6",
              "id": "declines",
              "label": "Declines, or asks for a biocompatible alternative"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Does the patient or parent accept the recommendation?"
        },
        {
          "detail": "Apply fluoride varnish or place the sealant per the practice's standard clinical steps for that procedure.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Proceed with standard fluoride or sealant application"
        },
        {
          "detail": "Chart note: recommendation given, patient's stated reason if declined, alternative offered/used, dentist sign-off where applicable, and the signed informed refusal on file.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Document the recommendation, decline or alternative, and sign-off"
        },
        {
          "detail": "Fluoride/sealant discussion complete",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Fluoride/sealant discussion complete"
        },
        {
          "detail": "Ask whether the concern is a chemical/material sensitivity, a biologic or holistic care preference, or something else — the follow-up differs by reason.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Explore the reason for the decline"
        },
        {
          "detail": "Describe generic options the practice may carry (e.g., a fluoride-free remineralizing agent, a resin-based sealant material without the specific component the patient objects to) — named generically, never by brand.\n\nWhy: The practice can accommodate the preference without endorsing a specific commercial product line in a clinical protocol.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "biocompatible/alternative product information sheet"
          ],
          "role": "hygienist",
          "title": "Offer a generic biocompatible or fluoride-free alternative if one is stocked",
          "why": "The practice can accommodate the preference without endorsing a specific commercial product line in a clinical protocol."
        },
        {
          "detail": "Before finalizing an alternative or a full decline, the treating dentist reviews the caries risk and the substitution to confirm it does not create an unaddressed clinical risk.\n\nWhy: A hygienist can offer alternatives within scope, but the treating dentist owns the clinical risk assessment behind an accepted material substitution.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the material substitution and refusal is clinically appropriate.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the material substitution and refusal is clinically appropriate",
          "why": "A hygienist can offer alternatives within scope, but the treating dentist owns the clinical risk assessment behind an accepted material substitution."
        },
        {
          "detail": "Have the patient or parent read and sign the informed refusal (or alternative-acceptance) form before the visit closes.\n\nWhy: A verbal decline without a signed record is the single most common gap found in a chart audit for this scenario.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Patient or parent signs the informed refusal or alternative-acceptance form.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "materials": [
            "informed refusal form"
          ],
          "role": "hygienist",
          "title": "Patient or parent signs the informed refusal or alternative-acceptance form",
          "why": "A verbal decline without a signed record is the single most common gap found in a chart audit for this scenario."
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Patient declines fluoride or sealants, or requests biocompatible material alternatives — A patient or parent refuses fluoride or asks for fluoride-free, BPA-free or metal-free options.",
      "title": "Patient declines fluoride or sealants, or requests biocompatible material alternatives",
      "trigger": "A patient or parent refuses fluoride or asks for fluoride-free, BPA-free or metal-free options",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "No ADA or AAPD guidance document addresses periodontal/caries causes of oral malodor — the cited ADA Living Guidelines hub does not list this topic and no matching AAPD document was found — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "The ADA hub's own guideline list (fetched): Anesthesia & Sedation, Antibiotic Stewardship & Prophylaxis, Caries Management/Prevention/Periodontitis treatment, Oral Cancer, Pain Management, Radiography & Radiation Safety — no halitosis or oral-malodor entry.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAPD evidence-based guidance on periodontal and caries causes of oral malodor (openly published)",
              "url": "https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research"
            }
          },
          "source": "No verified ADA/AAPD authority at the cited URL — generic functional equivalent for halitosis assessment and management"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "source": "AAP/EFP 2017 Classification of Periodontal and Peri-implant Diseases",
          "url": "https://www.perio.org/"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "hyg-019",
      "kind": "clinical",
      "materials": [
        "tongue scraper for demonstration",
        "patient handout on oral vs. systemic causes"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ask about onset, timing (morning vs. constant), diet, dry mouth symptoms, tobacco use, and whether it was self-noticed or reported by someone else.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Take a brief halitosis history"
        },
        {
          "detail": "Check for: active periodontal disease or bleeding on probing, visible caries, tongue coating, dry mouth (reduced salivary flow), ill-fitting appliance, and poor interdental cleaning.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Screen for common oral causes"
        },
        {
          "detail": "Was an oral cause identified?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "oral-cause-yes",
              "label": "An oral cause was identified"
            },
            {
              "goto": "s7",
              "id": "oral-cause-no",
              "label": "No oral cause found despite the checklist"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Was an oral cause identified?"
        },
        {
          "detail": "Treat within scope: periodontal debridement referral if disease is present, tongue-cleaning instruction, interdental cleaning instruction, or note the caries for restorative follow-up.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Address the identified oral cause"
        },
        {
          "detail": "Chart note: reported symptom, checklist findings, cause identified and treatment given, or referral suggestion made and dentist sign-off.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Document the halitosis assessment and outcome"
        },
        {
          "detail": "Halitosis assessment complete",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Halitosis assessment complete"
        },
        {
          "detail": "Note any signs suggesting a non-oral cause: sinus/post-nasal symptoms, reflux symptoms, diabetes history, or tonsil stones — these point outside the dental scope.\n\nWhy: Persistent halitosis with a clean oral exam is a known marker for systemic causes the dental team cannot treat, and should not be dismissed as untreatable.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Review for systemic red flags before considering a medical referral",
          "why": "Persistent halitosis with a clean oral exam is a known marker for systemic causes the dental team cannot treat, and should not be dismissed as untreatable."
        },
        {
          "detail": "The treating dentist confirms no oral cause was missed and agrees the case warrants a referral suggestion to the patient's physician or ENT.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews findings before a medical referral is suggested.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews findings before a medical referral is suggested"
        },
        {
          "detail": "Give the patient a written note suggesting they discuss persistent halitosis with their physician, since the dental exam found no oral cause.",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Hand the referral suggestion to the patient"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Halitosis assessment and management — A patient reports bad breath or a partner's complaint.",
      "title": "Halitosis assessment and management",
      "trigger": "A patient reports bad breath or a partner's complaint",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC HPV vaccination and oropharyngeal cancer risk guidance (public domain)",
          "source": "CDC HPV vaccination and oropharyngeal cancer risk guidance (public domain)",
          "url": "https://www.cdc.gov/hpv/"
        },
        {
          "kind": "open_standard",
          "label": "ADA evidence-based guidance on the dental team's role in oral cancer screening and HPV counseling (openly published)",
          "source": "ADA evidence-based guidance on the dental team's role in oral cancer screening and HPV counseling (openly published)",
          "url": "https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hyg-020",
      "kind": "clinical",
      "materials": [
        "public health HPV/oral cancer patient handout"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Perform the standard soft-tissue and oropharyngeal visual/palpation screening that is already part of the recall exam.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Complete the routine oral cancer screening as part of the visit"
        },
        {
          "detail": "Using CDC-sourced language, briefly explain that HPV is a known risk factor for oropharyngeal cancer and that vaccination is a prevention option recommended in adolescence and young adulthood.\n\nWhy: The dental visit is often a patient's only recurring healthcare touchpoint at this age, making it a public-health-recommended place to raise the topic.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "public health HPV/oral cancer patient handout"
          ],
          "role": "hygienist",
          "title": "Introduce the HPV–oropharyngeal cancer link using public health materials",
          "why": "The dental visit is often a patient's only recurring healthcare touchpoint at this age, making it a public-health-recommended place to raise the topic."
        },
        {
          "detail": "Does the patient or parent want a vaccination referral or more information?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "wants-referral",
              "label": "Wants a referral or more information"
            },
            {
              "goto": "s5",
              "id": "no-further-action",
              "label": "No further action requested today"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Does the patient or parent want a vaccination referral or more information?"
        },
        {
          "detail": "Give the patient a written vaccination-resource note pointing to their primary care physician or a public health clinic; the dental team does not administer the vaccine.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Hand off to the patient's physician or a vaccination resource"
        },
        {
          "detail": "Chart note: HPV/oral cancer counseling given, referral offered or declined — no clinical detail beyond that the conversation occurred.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Document that the counseling was offered"
        },
        {
          "detail": "HPV counseling conversation complete",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "HPV counseling conversation complete"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "HPV vaccination counseling and oropharyngeal cancer risk conversation — An adolescent or young-adult recall visit, or a patient asks about HPV and oral cancer.",
      "title": "HPV vaccination counseling and oropharyngeal cancer risk conversation",
      "trigger": "An adolescent or young-adult recall visit, or a patient asks about HPV and oral cancer",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC infection control guidance for dental settings (public domain)",
          "source": "CDC infection control guidance for dental settings (public domain)",
          "url": "https://www.cdc.gov/oral-health/"
        },
        {
          "kind": "open_standard",
          "label": "No ADA guideline addresses herpetic-lesion elective-care deferral — the ADA Living Guidelines hub cited does not include this topic; deferral-until-healed guidance appears in non-ADA clinical literature (e.g., AAOM) that this session could not independently fetch and verify text from — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "The ADA hub's own guideline list (fetched): Anesthesia & Sedation, Antibiotic Stewardship & Prophylaxis, Caries Management/Prevention, Oral Cancer, Pain Management, Periodontal Disease/Periodontitis, Radiography & Radiation Safety — no herpetic-lesion or oral-malodor entry. My own attempt to fetch the AAOM clinical practice statement page was blocked by network egress, so I could not read its text to confirm the exact deferral language myself.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA evidence-based guidance on herpetic lesions and elective dental care deferral (openly published)",
              "url": "https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research"
            }
          },
          "source": "No verified ADA/AAPD authority at the cited URL — generic functional equivalent for 'defer elective care while an active contagious oral lesion is present'"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hyg-021",
      "kind": "clinical",
      "materials": [
        "barrier precaution supplies (mask, gloves, eye protection)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "During check-in or seating, note any visible cold sore, vesicular cluster, or weeping lesion on the lips or perioral skin.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Visually screen for an active herpetic or vesicular lesion before seating for treatment"
        },
        {
          "detail": "The treating dentist visually confirms the lesion and decides whether elective care must be deferred for that visit.\n\nWhy: Deferring a scheduled procedure has patient-relationship and rescheduling consequences, so the call sits with the treating dentist, not the screening hygienist alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the finding and the deferral decision.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the finding and the deferral decision",
          "why": "Deferring a scheduled procedure has patient-relationship and rescheduling consequences, so the call sits with the treating dentist, not the screening hygienist alone."
        },
        {
          "detail": "Is today's planned care elective, or is there an urgent problem needing attention?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "defer-elective",
              "label": "Defer all elective care to a later visit"
            },
            {
              "goto": "s7",
              "id": "urgent-only",
              "label": "Address only an urgent, non-elective problem with added barrier precautions"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is today's planned care elective, or is there an urgent problem needing attention?"
        },
        {
          "detail": "Front desk reschedules the elective procedure for after the lesion has healed and explains the reason to the patient in plain, non-alarming terms.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to front desk to reschedule"
        },
        {
          "detail": "Chart note: lesion observed, dentist confirmation, decision to defer elective care (or urgent-only treatment given), and rescheduling outcome.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the lesion finding and the deferral decision"
        },
        {
          "detail": "Lesion deferral handled",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Lesion deferral handled"
        },
        {
          "detail": "If there is a true urgent problem (e.g., significant pain, abscess), treat only that issue, using extra barrier precautions and avoiding contact with the lesion site; still defer the elective portion.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "barrier precaution supplies (mask, gloves, eye protection)"
          ],
          "role": "dentist",
          "title": "Provide only the urgent care needed, with added barrier precautions"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Active herpetic lesion or contagious oral lesion at visit: defer elective care — A patient arrives with an active cold sore or vesicular lesion.",
      "title": "Active herpetic lesion or contagious oral lesion at visit: defer elective care",
      "trigger": "A patient arrives with an active cold sore or vesicular lesion",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA evidence-based guidance on oral piercing risks and complication management (openly published)",
          "source": "ADA evidence-based guidance on oral piercing risks and complication management (openly published)",
          "url": "https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research"
        },
        {
          "kind": "public_domain",
          "label": "CDC infection control and oral health guidance (public domain)",
          "source": "CDC infection control and oral health guidance (public domain)",
          "url": "https://www.cdc.gov/oral-health/"
        }
      ],
      "class": "hygiene-preventive",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "hyg-022",
      "kind": "clinical",
      "materials": [
        "oral piercing risk-counseling handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Record the piercing location (tongue, lip, cheek) and jewelry type, or note that the patient is asking about getting a piercing.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Note the oral piercing during the exam, or the patient's question about getting one"
        },
        {
          "detail": "Check for: chipped or fractured teeth from jewelry contact, gingival recession at the jewelry site, signs of infection or excessive swelling, and jewelry looseness/embedding risk.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Check for common piercing complications"
        },
        {
          "detail": "Is a complication present?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "complication-yes",
              "label": "A complication is present (chip, recession, infection signs)"
            },
            {
              "goto": "s8",
              "id": "complication-no",
              "label": "No complication found; patient has or is considering a piercing"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is a complication present?"
        },
        {
          "detail": "The treating dentist examines the chip, recession, or suspected infection and determines whether restorative treatment, monitoring, or a specialist referral is needed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist evaluates the complication before any restorative or referral decision.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist evaluates the complication before any restorative or referral decision"
        },
        {
          "detail": "Route the finding to restorative treatment planning if a chip needs repair, or to a specialist referral if infection signs suggest care beyond the practice's scope.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off for restorative treatment planning or specialist referral"
        },
        {
          "detail": "Chart note: piercing noted, checklist findings, dentist evaluation and disposition if a complication was present, or counseling given.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Document the piercing finding and outcome"
        },
        {
          "detail": "Oral piercing counseling/complication handling complete",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Oral piercing counseling/complication handling complete"
        },
        {
          "detail": "Explain the known risks (chipping, recession, infection, jewelry aspiration) and give guidance on jewelry material, sizing, and cleaning around the site.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "oral piercing risk-counseling handout"
          ],
          "role": "hygienist",
          "title": "Provide risk counseling and hygiene guidance"
        }
      ],
      "subclass": "hygiene-and-preventive-care",
      "summary": "Oral piercing counseling and complication management — A patient has a tongue or lip piercing with chipping, recession or infection, or asks about getting one.",
      "title": "Oral piercing counseling and complication management",
      "trigger": "A patient has a tongue or lip piercing with chipping, recession or infection, or asks about getting one",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        },
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "impl-001",
      "kind": "clinical",
      "materials": [
        "medical history form (antiresorptive/bisphosphonate, anticoagulant, diabetes, smoking questions)",
        "intraoral exam findings",
        "panoramic or existing radiographs",
        "candidacy checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Dentist asks what tooth or teeth are missing, how long, and what the patient expects from replacement (chewing function, appearance, or both).\n\nWhy: Candidacy screening starts from what the patient wants restored, which shapes whether a fixed or removable solution is even relevant later.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Gather the patient's chief concern and expectations",
          "why": "Candidacy screening starts from what the patient wants restored, which shapes whether a fixed or removable solution is even relevant later."
        },
        {
          "detail": "Dentist checks: current or past antiresorptive/bisphosphonate therapy, anticoagulant use, uncontrolled diabetes, active smoking, history of head/neck radiation, immunosuppression, patient age and skeletal maturity (implants are contraindicated until skeletal growth is complete), and active or uncontrolled periodontal disease.\n\nWhy: Each of these factors changes healing risk and may require a medical consult or a modified surgical plan before implant placement is offered.\n\nRecord: medical history checklist results in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Review medical history for implant risk factors",
          "why": "Each of these factors changes healing risk and may require a medical consult or a modified surgical plan before implant placement is offered."
        },
        {
          "detail": "Dentist reviews existing radiographs (panoramic or prior periapicals) for a first-pass read on bone height, adjacent tooth position, and proximity to the nerve canal or sinus floor.\n\nWhy: A first-pass anatomic read tells the dentist whether the site looks straightforward or likely to need grafting or advanced imaging, before committing the patient to a full workup.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review available bone volume and site anatomy from existing imaging",
          "why": "A first-pass anatomic read tells the dentist whether the site looks straightforward or likely to need grafting or advanced imaging, before committing the patient to a full workup."
        },
        {
          "detail": "Dentist weighs medical history findings (including skeletal maturity and periodontal disease control), site anatomy, and complexity against their own training and the practice's scope.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "proceed-in-house",
              "label": "No unmanaged risk factors, site looks favorable — proceed to CBCT and planning"
            },
            {
              "goto": "s9",
              "id": "medical-consult-first",
              "label": "Antiresorptive, anticoagulant, or uncontrolled systemic condition present — obtain a medical consult before proceeding"
            },
            {
              "goto": "s10",
              "id": "refer-out",
              "label": "Anatomy or complexity beyond in-house scope — refer to a specialist"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide candidacy pathway"
        },
        {
          "detail": "Dentist or treatment coordinator explains the general implant process (planning imaging, surgery, healing, restoration), an approximate timeline, and a cost range before any commitment.\n\nWhy: Informed consent starts with the patient understanding the multi-step, multi-month nature of implant treatment before scheduling begins.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Discuss implant option, timeline, and cost range with the patient",
          "why": "Informed consent starts with the patient understanding the multi-step, multi-month nature of implant treatment before scheduling begins."
        },
        {
          "detail": "Dentist signs off on the candidacy pathway chosen — proceed in-house, medical consult first, or referral — and confirms it in the chart before the treatment coordinator schedules the next step (imaging, consult request, or referral).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on candidacy decision before the next step.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on candidacy decision before the next step"
        },
        {
          "detail": "Treatment coordinator documents the candidacy pathway (proceed, medical consult, or referral), the reasoning, and the next scheduled step in the chart and scheduling system.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Log the candidacy decision and next step"
        },
        {
          "detail": "Candidacy screening complete",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Candidacy screening complete"
        },
        {
          "detail": "Treatment coordinator prepares a consult request naming the specific risk factor (e.g. antiresorptive therapy duration and route) for the patient's physician to clear or advise on before implant surgery is scheduled.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to the patient's physician for a medical consult"
        },
        {
          "detail": "Treatment coordinator provides the patient a specialist referral with the screening summary and reason for referral (e.g. severe bone deficit, complex anatomy).",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to specialist referral"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Implant candidacy and risk screening (bone, systemic, habits, antiresorptives) — A patient asks about replacing a missing tooth with an implant.",
      "title": "Implant candidacy and risk screening (bone, systemic, habits, antiresorptives)",
      "trigger": "A patient asks about replacing a missing tooth with an implant",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        },
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "open_standard",
          "label": "ALARA radiation-exposure principle (public health standard)",
          "source": "ALARA radiation-exposure principle (public health standard)"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "impl-002",
      "kind": "clinical",
      "materials": [
        "CBCT unit",
        "radiographic or scan-body guide (if used)",
        "planning software",
        "diagnostic wax-up or digital tooth setup",
        "lead apron / thyroid collar"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Dentist confirms which site is being planned and what the final restoration should look like (single crown, bridge abutment, or overdenture support) before scanning.\n\nWhy: Prosthetically driven planning starts from the finished tooth position, not from bone alone — scanning without a restorative goal risks placing the implant in the wrong 3D position.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the CBCT order and restorative goal",
          "why": "Prosthetically driven planning starts from the finished tooth position, not from bone alone — scanning without a restorative goal risks placing the implant in the wrong 3D position."
        },
        {
          "detail": "Assistant positions the patient, applies a lead apron/thyroid collar, and captures the CBCT using the smallest field of view and lowest exposure settings that still resolve the site.\n\nWhy: ALARA (as low as reasonably achievable) is the public-health standard for any ionizing radiation exposure.\n\nRecord: radiation dose and field-of-view settings in the chart",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Acquire the CBCT scan at the lowest dose consistent with diagnostic needs",
          "why": "ALARA (as low as reasonably achievable) is the public-health standard for any ionizing radiation exposure."
        },
        {
          "detail": "Dentist reviews bone height and width, nerve canal position, sinus floor position, adjacent root proximity, and bone density at the planned site.\n\nWhy: Every landmark on this checklist is a hard stop or modifier for implant length, angulation, and whether grafting is needed first.\n\nRecord: anatomic landmark findings in the chart",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review CBCT for anatomic landmarks",
          "why": "Every landmark on this checklist is a hard stop or modifier for implant length, angulation, and whether grafting is needed first."
        },
        {
          "detail": "Dentist or lab liaison imports a diagnostic wax-up or digital tooth setup into the planning software and overlays it on the CBCT to plan implant position, angulation, and depth from the restoration backward.\n\nWhy: Placing the virtual crown first and the implant second keeps the surgery driven by the final tooth position rather than by bone convenience alone.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Overlay the planned restoration (wax-up or digital tooth setup) on the scan",
          "why": "Placing the virtual crown first and the implant second keeps the surgery driven by the final tooth position rather than by bone convenience alone."
        },
        {
          "detail": "Dentist evaluates whether bone volume and anatomy support the planned implant position without additional procedures.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "plan-as-drawn",
              "label": "Bone volume and anatomy support the plan — finalize and order a surgical guide"
            },
            {
              "goto": "s10",
              "id": "graft-first",
              "label": "Bone deficit present — plan a grafting procedure before implant placement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether the site supports the plan as drawn"
        },
        {
          "detail": "Lab liaison exports the finalized implant position, angulation, depth, and dimensions from the planning software and sends the file to the lab for guide fabrication.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Finalize the implant plan and export for the surgical guide"
        },
        {
          "detail": "Dentist reviews and signs off on the planning decision reached — either the finalized implant position and dimensions, before the plan file leaves the office, or the decision to defer to grafting, before the case is handed to the grafting workflow — and confirms it in the chart.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the planning decision.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the planning decision"
        },
        {
          "detail": "Dentist documents the finalized implant position, dimensions, and any grafting decision in the chart, and notes the guide order status.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Log the finalized plan and site"
        },
        {
          "detail": "Planning complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Planning complete"
        },
        {
          "detail": "Dentist documents the bone deficit and hands the case to the treatment-planning workflow to sequence a grafting procedure ahead of implant placement.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the grafting treatment plan"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "CBCT acquisition and prosthetically driven implant planning — The candidate is approved; site anatomy and the restorative position must be planned.",
      "title": "CBCT acquisition and prosthetically driven implant planning",
      "trigger": "The candidate is approved; site anatomy and the restorative position must be planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "impl-003",
      "kind": "clinical",
      "materials": [
        "printed or lab-fabricated surgical guide",
        "sleeve/drill-key set matching the guide system",
        "disinfectant for the guide",
        "planning file for comparison"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Assistant compares the received guide's sleeve positions and site markings against the finalized planning file to confirm they match before scheduling the fit check.\n\nWhy: Catching a fabrication mismatch here, away from chairside time pressure, avoids discovering it with the patient already seated.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Inspect the guide against the planning file on arrival",
          "why": "Catching a fabrication mismatch here, away from chairside time pressure, avoids discovering it with the patient already seated."
        },
        {
          "detail": "Assistant disinfects the guide with an EPA-registered intermediate-level surface disinfectant wipe or spray, held wet for the manufacturer's stated contact time (typically 1-3 minutes), following the protocol appropriate to the guide's material (printed resin or milled), before it touches the patient's mouth.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the guide per its material's disinfection protocol"
        },
        {
          "detail": "Dentist seats the guide and checks: full seating without rocking, correct tooth or tissue support contacts, sleeve access and angulation reachable with the drill system, and no interference with soft tissue or adjacent teeth.\n\nWhy: A guide that rocks or is off by even a small margin transfers that error directly into implant position, so verification happens before the patient is draped for surgery.\n\nRecord: fit-check findings in the chart",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Try the guide in intraorally and check fit",
          "why": "A guide that rocks or is off by even a small margin transfers that error directly into implant position, so verification happens before the patient is draped for surgery."
        },
        {
          "detail": "Dentist decides whether the guide fits accurately enough to proceed or needs to be remade.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "guide-approved",
              "label": "Guide seats fully and matches the plan — approve for surgery"
            },
            {
              "goto": "s9",
              "id": "guide-remake",
              "label": "Guide rocks, misaligns, or interferes with tissue — reject and order a remake"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether the guide is surgery-ready"
        },
        {
          "detail": "Dentist signs off in the chart that the guide is verified and approved for use before it is placed with the drill kit for the scheduled surgery.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off approving the guide for surgical use.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off approving the guide for surgical use"
        },
        {
          "detail": "Assistant confirms the drill key set matching the guide's sleeve system is sterilized and available for the scheduled surgery date.\n\nWhy: A guide is useless without its matching drill kit, and this is confirmed ahead of the surgery day rather than discovered at the tray setup.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the matching drill key and sleeve kit is on hand",
          "why": "A guide is useless without its matching drill kit, and this is confirmed ahead of the surgery day rather than discovered at the tray setup."
        },
        {
          "detail": "Dentist or assistant documents whether the guide was approved or sent for remake, and confirms the surgery-ready status in the chart.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the guide fit-check result"
        },
        {
          "detail": "Guide verification complete",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Guide verification complete"
        },
        {
          "detail": "Lab liaison notifies the lab of the specific fit issue found and requests a remake before rescheduling surgery.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to the lab for a guide remake"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Surgical guide design verification and intraoral fit check — A guide is printed or received from the lab before surgery.",
      "title": "Surgical guide design verification and intraoral fit check",
      "trigger": "A guide is printed or received from the lab before surgery",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "per-use",
      "id": "impl-004",
      "kind": "clinical",
      "materials": [
        "sterile surgical tray and drapes",
        "implant fixture and matching drill kit",
        "surgical guide (if guided)",
        "torque wrench",
        "local anesthesia setup",
        "sterile saline irrigation (syringe or handpiece-delivered)",
        "suture kit",
        "sterile gloves and gown",
        "emergency kit (oxygen, emergency medications)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If a medical emergency occurs at any point during this procedure, call 911 / activate EMS immediately and begin the office's medical emergency response before anything else. Before starting, dentist confirms the emergency kit, oxygen, and emergency contact protocol are in place and staff know their roles.\n\nWhy: Any surgical procedure carries a small risk of a medical emergency (syncope, allergic reaction, cardiac event); readiness is confirmed before the patient is draped, not after a problem starts.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm emergency response readiness before beginning surgery.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm emergency response readiness before beginning surgery",
          "why": "Any surgical procedure carries a small risk of a medical emergency (syncope, allergic reaction, cardiac event); readiness is confirmed before the patient is draped, not after a problem starts."
        },
        {
          "detail": "Assistant confirms the signed consent form matches today's planned procedure and dentist verbally confirms the correct tooth site with the patient before draping.\n\nWhy: Site verification immediately before incision is the standard safeguard against wrong-site surgery.\n\nRecord: site verification confirmation in the chart",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Verify signed consent and correct surgical site",
          "why": "Site verification immediately before incision is the standard safeguard against wrong-site surgery."
        },
        {
          "detail": "Sterilization tech confirms all instruments are from verified sterile packaging with intact indicators, assistant sets up the sterile field and drapes, and dentist and assistant gown and glove using sterile technique.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Complete sterile field and instrument setup"
        },
        {
          "detail": "Dentist reconfirms with the patient any changes to medications (including new anticoagulant or antiresorptive therapy), allergies, and health status since the candidacy screening, immediately before local anesthesia is given.\n\nWhy: The candidacy screening in impl-001 may have happened weeks or months earlier; medications and health status can change between that visit and surgery day.\n\nRecord: confirmed current medications, allergies, and health-status changes in the chart",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Reconfirm current medications, allergies, and health status before anesthesia",
          "why": "The candidacy screening in impl-001 may have happened weeks or months earlier; medications and health status can change between that visit and surgery day."
        },
        {
          "detail": "Dentist administers local anesthesia to the surgical site and confirms adequate numbness before proceeding.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Dentist reflects a flap if the approach is open, then prepares the osteotomy following the planned sequence of drill diameters and depths, using the surgical guide if the case is guided, drilling under copious sterile saline irrigation throughout to prevent thermal necrosis of the osteotomy walls.\n\nWhy: Following the pre-planned drill sequence and depth is what keeps the final implant position matching the prosthetically driven plan from impl-002.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Reflect tissue (if needed) and prepare the osteotomy per the plan",
          "why": "Following the pre-planned drill sequence and depth is what keeps the final implant position matching the prosthetically driven plan from impl-002."
        },
        {
          "detail": "Dentist checks drill depth against the plan and the patient's response for signs of nerve or sinus proximity (e.g. unexpected bleeding pattern, patient discomfort despite anesthesia).",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "depth-on-plan",
              "label": "Depth and anatomy match the plan with no concerning signs — proceed to fixture placement"
            },
            {
              "goto": "s14",
              "id": "anatomy-concern",
              "label": "Signs of nerve or sinus encroachment — stop and escalate"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm osteotomy depth stayed within the planned safety margin"
        },
        {
          "detail": "Dentist confirms in the chart that osteotomy depth and anatomy check are within the planned safety margin before the implant fixture itself is placed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before fixture placement.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before fixture placement"
        },
        {
          "detail": "Dentist places the implant fixture using the torque wrench, seating to the planned depth and recording the final insertion torque value achieved.\n\nRecord: final insertion torque value in the chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Place the implant fixture to the planned depth and torque"
        },
        {
          "detail": "Dentist places a healing abutment (if immediate) or cover screw (if submerged) and sutures the site per the planned closure technique.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Place a healing cap or cover screw and close the site"
        },
        {
          "detail": "Assistant reviews written post-operative instructions (bleeding, swelling, diet, medication) with the patient and schedules a follow-up visit.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions and schedule follow-up"
        },
        {
          "detail": "Dentist documents the procedure performed, implant dimensions, final torque, any complication, and follow-up plan in the chart.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Log the surgical note"
        },
        {
          "detail": "Surgery complete",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Surgery complete"
        },
        {
          "detail": "Dentist stops the osteotomy and follows the intraoperative nerve-or-sinus-encroachment protocol (impl-012) rather than continuing placement.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the nerve/sinus encroachment protocol"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Implant placement surgery — sterile setup, sequence, torque and closure — The patient is seated for implant placement with consent signed.",
      "title": "Implant placement surgery — sterile setup, sequence, torque and closure",
      "trigger": "The patient is seated for implant placement with consent signed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "per-use",
      "id": "impl-005",
      "kind": "clinical",
      "materials": [
        "sterile extraction and implant surgical tray",
        "periotome/elevators for atraumatic extraction",
        "local anesthesia setup",
        "implant fixture sized for immediate placement",
        "bone graft material for the gap jumping distance",
        "membrane (if indicated)",
        "torque wrench",
        "sterile saline irrigation (syringe or handpiece-delivered)",
        "suture kit",
        "emergency kit (oxygen, emergency medications)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If a medical emergency occurs at any point during this procedure, call 911 / activate EMS immediately and begin the office's medical emergency response before anything else. Before starting, dentist confirms the emergency kit, oxygen, and emergency contact protocol are in place.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm emergency response readiness before beginning surgery.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm emergency response readiness before beginning surgery"
        },
        {
          "detail": "Dentist administers local anesthesia to the extraction and implant site and confirms adequate numbness before proceeding.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Dentist extracts the tooth using periotomes and controlled elevation technique to preserve the buccal and lingual/palatal socket walls intact.\n\nWhy: Immediate placement depends on intact socket walls for primary stability and to contain the graft material; a fractured wall changes the plan.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Perform an atraumatic extraction preserving socket walls",
          "why": "Immediate placement depends on intact socket walls for primary stability and to contain the graft material; a fractured wall changes the plan."
        },
        {
          "detail": "Dentist checks: all four socket walls intact, no purulence or acute infection in the socket, adequate apical and lateral bone beyond the socket for primary stability.\n\nRecord: socket assessment findings in the chart",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Assess the socket after extraction"
        },
        {
          "detail": "Dentist weighs socket wall integrity, infection status, and expected primary stability against proceeding immediately or delaying.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "proceed-immediate",
              "label": "Walls intact, no active infection, apical bone adequate — proceed with immediate placement"
            },
            {
              "goto": "s14",
              "id": "convert-delayed",
              "label": "Wall fracture, active infection, or insufficient apical bone — convert to socket preservation and delayed placement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether to proceed with immediate placement"
        },
        {
          "detail": "Dentist confirms in the chart that socket assessment supports immediate placement before the osteotomy is prepared.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off approving immediate placement.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off approving immediate placement"
        },
        {
          "detail": "Dentist prepares the osteotomy engaging bone beyond the socket walls to achieve primary stability, following the planned drill sequence, drilling under copious sterile saline irrigation to prevent thermal necrosis of the osteotomy walls.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the osteotomy apical and/or palatal to the socket per the plan"
        },
        {
          "detail": "Dentist places the fixture to the planned depth and torque, and confirms primary stability meets the practice's target threshold.\n\nRecord: primary stability torque value in the chart",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Place the implant fixture and check primary stability"
        },
        {
          "detail": "Dentist places bone graft material into the residual gap between the implant surface and the socket walls, and a membrane if indicated.\n\nWhy: Grafting the gap supports bone fill around an implant placed narrower than the socket, which immediate placement typically produces.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Graft the jumping gap between the implant and socket walls",
          "why": "Grafting the gap supports bone fill around an implant placed narrower than the socket, which immediate placement typically produces."
        },
        {
          "detail": "Dentist places a healing abutment (if primary stability supports it) or cover screw, and sutures the soft tissue over or around it per the plan.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Place a healing abutment or cover screw and close the site"
        },
        {
          "detail": "Assistant reviews written post-operative instructions with the patient and schedules a follow-up visit.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions and schedule follow-up"
        },
        {
          "detail": "Dentist documents extraction findings, socket assessment, decision (immediate vs delayed), implant dimensions and torque (if placed), graft material used, and follow-up plan.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Log the procedure note"
        },
        {
          "detail": "Procedure complete",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Procedure complete"
        },
        {
          "detail": "Dentist places a socket preservation graft instead, documents the reason for conversion, and schedules the case for CBCT and re-planning (impl-002) after healing.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to socket preservation and re-plan for delayed placement"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Immediate implant placement into a fresh extraction socket — An extraction with intact socket walls where immediate placement is planned.",
      "title": "Immediate implant placement into a fresh extraction socket",
      "trigger": "An extraction with intact socket walls where immediate placement is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "impl-006",
      "kind": "clinical",
      "materials": [
        "tissue punch or small flap kit",
        "healing abutment set",
        "torque driver",
        "local anesthesia setup",
        "sterile instruments"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Assistant confirms the time elapsed since placement (per the surgical note) meets the planned healing interval for the bone type and case before scheduling uncovery.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the planned healing interval has elapsed"
        },
        {
          "detail": "Dentist checks for tenderness, mobility on gentle testing, and radiographic bone level around the fixture before proceeding to uncover.\n\nWhy: Uncovering an implant that has not integrated exposes it to load and contamination risk before it is ready.\n\nRecord: integration assessment findings in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Assess clinical signs of integration before uncovering",
          "why": "Uncovering an implant that has not integrated exposes it to load and contamination risk before it is ready."
        },
        {
          "detail": "Dentist weighs the integration assessment against proceeding today or delaying further.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "proceed-uncover",
              "label": "No tenderness or mobility, bone level stable — proceed with uncovery"
            },
            {
              "goto": "s8",
              "id": "delay-uncovery",
              "label": "Signs of incomplete integration — delay and reassess in a few weeks"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether to proceed with uncovery"
        },
        {
          "detail": "Dentist confirms in the chart that the integration assessment supports proceeding before anesthesia and access begin.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off approving uncovery.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off approving uncovery"
        },
        {
          "detail": "Dentist administers local anesthesia, then accesses the cover screw using a tissue punch or small flap depending on tissue thickness and case type.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia and access the implant cover screw"
        },
        {
          "detail": "Dentist removes the cover screw, confirms clean fixture threads, and hand-torques a healing abutment of the appropriate height and diameter for the case.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Remove the cover screw and place a healing abutment"
        },
        {
          "detail": "Dentist checks that the healing abutment shapes the surrounding soft tissue appropriately and sutures the site if a flap was used.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Check soft tissue contour around the healing abutment"
        },
        {
          "detail": "Dentist documents the integration assessment, the decision (proceed or delay), the healing abutment placed (if any), and the next scheduled step.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Log the uncovery procedure"
        },
        {
          "detail": "Second-stage procedure complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Second-stage procedure complete"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Second-stage uncovery and healing abutment placement — The osseointegration period is complete after a submerged placement.",
      "title": "Second-stage uncovery and healing abutment placement",
      "trigger": "The osseointegration period is complete after a submerged placement",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "generic",
          "label": "Standard implant-lab case communication practice: impression/scan, bite registration, shade, restoration/abutment specification, and requested turnaround date — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard implant-lab case communication practice: impression/scan, bite registration, shade, restoration/abutment specification, and requested turnaround date"
          },
          "source": "Standard implant-lab case communication practice: impression/scan, bite registration, shade, restoration/abutment specification, and requested turnaround date — Practice policy — no published authority governs this step."
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-use",
      "id": "impl-007",
      "kind": "clinical",
      "materials": [
        "implant-level impression coping or intraoral scan body",
        "digital scanner or impression material",
        "abutment options (stock or custom)",
        "torque wrench",
        "occlusion articulating paper",
        "cement or screw-retention hardware as applicable"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Dentist confirms the implant is stable and soft tissue around it is healthy and matured enough to capture an accurate impression or scan.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Verify implant stability and soft tissue readiness"
        },
        {
          "detail": "Assistant places the impression coping or scan body, and dentist captures either a conventional impression or a digital intraoral scan of the implant position along with opposing arch and bite registration.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Capture an implant-level impression or digital scan"
        },
        {
          "detail": "Dentist decides between a screw-retained or cement-retained restoration and stock versus custom abutment, based on implant angulation, emergence profile, and access.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "screw-retained",
              "label": "Access allows a favorable screw channel position — plan screw-retained restoration"
            },
            {
              "goto": "s4",
              "id": "cement-retained",
              "label": "Screw access would exit through the facial or angulation is unfavorable — plan cement-retained restoration on a custom abutment"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Select the restoration and abutment approach"
        },
        {
          "detail": "Lab liaison sends the scan or impression, bite registration, shade, and the selected restoration/abutment approach to the lab with a requested turnaround date.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send the case to the lab with restoration and abutment specifications"
        },
        {
          "detail": "Typical lab turnaround for abutment/crown fabrication is one to three weeks depending on case complexity and lab capacity; the patient returns for the try-in visit once the practice is notified the case has arrived. duration_min on this protocol reflects per-visit chair time, not this elapsed wait.",
          "id": "s5",
          "kind": "timer",
          "role": "lab-liaison",
          "timer_seconds": 1209600,
          "title": "Wait for the lab to fabricate the restoration"
        },
        {
          "detail": "Dentist tries in the abutment and crown, checks marginal fit, contacts, and occlusion with articulating paper, and adjusts as needed before final seating.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Try in and deliver the finished restoration"
        },
        {
          "detail": "Dentist confirms marginal fit, contacts, and occlusion are acceptable and signs off in the chart before torquing to final value and sealing or cementing.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before final torque and cementation/sealing.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before final torque and cementation/sealing"
        },
        {
          "detail": "Dentist torques the abutment or crown screw to the manufacturer's specified value using a calibrated torque wrench, then seals the access channel (screw-retained) or cements the crown (cement-retained), removing all excess cement.\n\nWhy: Under- or over-torquing risks screw loosening or fracture; excess cement left subgingivally is a documented cause of peri-implant disease.\n\nRecord: final torque value and retention type in the chart",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Torque the abutment/screw to spec and seal or cement",
          "why": "Under- or over-torquing risks screw loosening or fracture; excess cement left subgingivally is a documented cause of peri-implant disease."
        },
        {
          "detail": "Dentist confirms occlusion is even with adjacent and opposing teeth, and gives the patient implant-specific home care instructions.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Verify final occlusion and give home care instructions"
        },
        {
          "detail": "Dentist documents the restoration type, retention method, final torque, occlusion check, and home care instructions given.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Log the restoration delivery"
        },
        {
          "detail": "Restoration delivered",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Restoration delivered"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Implant-level impression or scan, abutment selection and crown delivery — The implant is integrated and ready to restore.",
      "title": "Implant-level impression or scan, abutment selection and crown delivery",
      "trigger": "The implant is integrated and ready to restore",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "generic",
          "label": "Standard implant-overdenture attachment workflow: healing-abutment exchange for attachment abutments, denture relief and fit check, chairside pickup of attachment housings",
          "source": "Standard implant-overdenture attachment workflow: healing-abutment exchange for attachment abutments, denture relief and fit check, chairside pickup of attachment housings"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-use",
      "id": "impl-008",
      "kind": "clinical",
      "materials": [
        "attachment abutments (matching implant system)",
        "pickup housing kit",
        "chairside pickup material",
        "denture (relieved for attachment housings)",
        "torque driver",
        "occlusion articulating paper"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Dentist confirms each implant supporting the overdenture is stable, soft tissue is healthy, and healing abutments are ready to be exchanged for attachment abutments.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Verify all implants are integrated and healthy"
        },
        {
          "detail": "Dentist removes each healing abutment and hand-torques the selected attachment abutment (e.g. ball, locator-style, or bar system) to the manufacturer's specified value on each implant.\n\nRecord: attachment abutment torque values per implant in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Remove healing abutments and place attachment abutments"
        },
        {
          "detail": "Assistant verifies the denture's intaglio surface has been relieved by the lab to seat fully without binding on the new attachment abutments.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Check the denture is relieved to seat over the attachment abutments"
        },
        {
          "detail": "Dentist checks that the denture fully seats over all attachment abutments without rocking or interference before proceeding to pickup.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "seats-correctly",
              "label": "Denture seats fully and passively — proceed to attachment pickup"
            },
            {
              "goto": "s3",
              "id": "needs-more-relief",
              "label": "Denture binds or rocks on an abutment — relieve further before pickup"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether the denture seats correctly for pickup"
        },
        {
          "detail": "Dentist confirms in the chart that the denture seats correctly before chairside pickup material is used intraorally.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before attachment pickup.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before attachment pickup"
        },
        {
          "detail": "Dentist places attachment housings over the abutments, seats the denture, and uses chairside pickup material to bond the housings into the denture base while the patient bites in centric occlusion.\n\nWhy: Chairside pickup captures the exact intraoral position of each attachment, which is more accurate than a lab-only estimate for retention alignment.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Pick up the attachment housings intraorally",
          "why": "Chairside pickup captures the exact intraoral position of each attachment, which is more accurate than a lab-only estimate for retention alignment."
        },
        {
          "detail": "Dentist trims excess pickup material, polishes the intaglio surface around the housings, and checks occlusion with articulating paper, adjusting as needed.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Finish, polish, and check occlusion"
        },
        {
          "detail": "Dentist seats the finished overdenture, checks retention and comfort with the patient, and gives written instructions on insertion/removal, cleaning around attachments, and a follow-up schedule.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Insert the finished overdenture and give home care instructions"
        },
        {
          "detail": "Dentist documents attachment abutments placed with torque values, pickup outcome, occlusion adjustment, and home care instructions given.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log the overdenture delivery"
        },
        {
          "detail": "Overdenture delivered",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Overdenture delivered"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Implant overdenture attachment pickup and delivery — An edentulous patient with integrated implants planned for an overdenture.",
      "title": "Implant overdenture attachment pickup and delivery",
      "trigger": "An edentulous patient with integrated implants planned for an overdenture",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        },
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "impl-009",
      "kind": "clinical",
      "materials": [
        "plastic or titanium-coated periodontal probe",
        "implant-safe (resin/titanium) curette or ultrasonic tip",
        "intraoral camera",
        "periapical/bitewing imaging system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Review implant placement date, restoration type (crown/bridge/overdenture), prior probing depths, and last radiograph date from the chart.\n\nWhy: Peri-implant baselines differ patient to patient; comparing today's findings to the patient's own history catches change earlier than a generic norm.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Pull implant history before seating the patient",
          "why": "Peri-implant baselines differ patient to patient; comparing today's findings to the patient's own history catches change earlier than a generic norm."
        },
        {
          "detail": "Check for erythema, edema, suppuration, and mucosal recession around each implant restoration before probing.\n\nWhy: Suppuration or bleeding on light contact can indicate peri-implant mucositis before probing depths change.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Visual and tactile exam of peri-implant tissue",
          "why": "Suppuration or bleeding on light contact can indicate peri-implant mucositis before probing depths change."
        },
        {
          "detail": "Record probing depths at 4–6 sites per implant using light force; note bleeding on probing (BOP) and any suppuration.\n\nWhy: A metal steel probe can scratch the implant surface or abutment; light force avoids false-positive pocket depths on a healthy implant.\n\nRecord: Probing depths, BOP, suppuration per implant site — patient chart",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Probe each implant with a plastic or titanium-coated probe",
          "why": "A metal steel probe can scratch the implant surface or abutment; light force avoids false-positive pocket depths on a healthy implant."
        },
        {
          "detail": "Compare last radiograph date to the practice's implant radiograph interval and today's clinical findings.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "due",
              "label": "Radiograph interval reached or bone-level concern noted"
            },
            {
              "goto": "s6",
              "id": "not-due",
              "label": "Radiograph not due and no clinical concern"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is a radiograph due this visit?"
        },
        {
          "detail": "Use a paralleling technique to get a reproducible bone-level view; compare to the prior radiograph for crestal bone change.\n\nWhy: Crestal bone loss is the key structural marker for peri-implantitis and is invisible on a visual/probing exam alone.\n\nRecord: Radiograph image + bone-level comparison note — patient chart",
          "id": "s5",
          "kind": "step",
          "materials": [
            "periapical/bitewing imaging system"
          ],
          "role": "hygienist",
          "title": "Capture a periapical radiograph of the implant",
          "why": "Crestal bone loss is the key structural marker for peri-implantitis and is invisible on a visual/probing exam alone."
        },
        {
          "detail": "Use plastic, resin, or titanium-coated curettes and implant-rated ultrasonic tips; confirm no stainless-steel scalers or standard ultrasonic tips will contact the implant or abutment surface.\n\nWhy: Stainless steel instruments can scratch the implant surface, creating a rougher surface that is harder to keep clean and more prone to biofilm accumulation.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "implant-safe (resin/titanium) curette or ultrasonic tip"
          ],
          "role": "hygienist",
          "title": "Select implant-safe instruments only",
          "why": "Stainless steel instruments can scratch the implant surface, creating a rougher surface that is harder to keep clean and more prone to biofilm accumulation."
        },
        {
          "detail": "Remove supra- and sub-mucosal deposits around each implant restoration; polish with a low-abrasive paste.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Debride accessible biofilm and calculus with implant-safe instruments"
        },
        {
          "detail": "Weigh BOP, suppuration, probing depth increase, and radiographic bone loss against the AAP peri-implant disease classification.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "healthy",
              "label": "No BOP, no suppuration, stable bone — peri-implant health"
            },
            {
              "goto": "s11",
              "id": "disease",
              "label": "BOP/suppuration present or bone loss noted — possible mucositis or peri-implantitis"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "hygienist",
          "title": "Are findings consistent with peri-implant disease?"
        },
        {
          "detail": "Schedule the next implant maintenance visit per the practice's default interval, shortened if disease was found.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Set the next recall interval"
        },
        {
          "detail": "Implant maintenance recall complete",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Implant maintenance recall complete"
        },
        {
          "detail": "The hygienist presents findings to the dentist; the dentist examines the implant and confirms the diagnosis and any treatment or referral plan before it is entered as a diagnosis in the chart.\n\nWhy: A peri-implant disease diagnosis and its treatment plan are clinical determinations that require the licensed dentist, not the hygienist alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on peri-implant disease finding and plan.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on peri-implant disease finding and plan",
          "why": "A peri-implant disease diagnosis and its treatment plan are clinical determinations that require the licensed dentist, not the hygienist alone."
        },
        {
          "detail": "Chart the confirmed diagnosis (mucositis or peri-implantitis), the dentist's plan (closer interval, non-surgical therapy, or specialist referral), and patient education given.\n\nRecord: Diagnosis, treatment plan, and patient education note — patient chart",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document diagnosis and plan"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Implant maintenance recall — probing, radiograph interval, instrument selection — A patient with implants returns for hygiene.",
      "title": "Implant maintenance recall — probing, radiograph interval, instrument selection",
      "trigger": "A patient with implants returns for hygiene",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "impl-010",
      "kind": "clinical",
      "materials": [
        "implant torque driver/wrench",
        "manufacturer torque specification sheet",
        "occlusal articulating paper",
        "cotton roll or gauze isolation",
        "access-hole filling material (PTFE tape + composite)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Gently test the restoration with a finger and mirror handle; distinguish a loose screw/crown (restoration moves, implant fixture does not) from a mobile implant (the fixture itself moves in bone).\n\nWhy: A loose screw is a routine chairside fix; a mobile implant fixture is a different, more serious problem (see the early implant failure protocol) and must not be retorqued.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Determine whether the mobility is the crown/screw or the implant itself",
          "why": "A loose screw is a routine chairside fix; a mobile implant fixture is a different, more serious problem (see the early implant failure protocol) and must not be retorqued."
        },
        {
          "detail": "Confirm with radiograph if the exam is inconclusive.",
          "forks": [
            {
              "goto": "s13",
              "id": "fixture-mobile",
              "label": "Implant fixture is mobile"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "restoration-only",
              "label": "Only the crown or screw is loose; fixture is stable"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the implant fixture itself mobile?"
        },
        {
          "detail": "The treating dentist confirms the fixture is stable and that a chairside retorque or recement (rather than referral or removal) is the correct next step before the assistant isolates the field.\n\nWhy: Choosing chairside repair over referral is a clinical judgment call that must rest with the licensed dentist before any instrument touches the restoration.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off that chairside repair is appropriate.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off that chairside repair is appropriate",
          "why": "Choosing chairside repair over referral is a clinical judgment call that must rest with the licensed dentist before any instrument touches the restoration."
        },
        {
          "detail": "Place cotton roll or gauze isolation; if the restoration is screw-retained, locate and clear the access hole, then back out the retaining screw with the correct driver.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the field and remove the crown if screw-retained"
        },
        {
          "detail": "Is the restoration screw-retained or cement-retained?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "screw",
              "label": "Screw-retained"
            },
            {
              "goto": "s15",
              "id": "cement",
              "label": "Cement-retained"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the restoration screw-retained or cement-retained?"
        },
        {
          "detail": "Check the screw threads for damage or wear, confirm the abutment seats fully and passively against the implant platform, and replace the screw if threads look worn per manufacturer guidance.\n\nWhy: A worn or damaged screw thread will loosen again even after a correct retorque; catching it now avoids a repeat visit.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Inspect the screw and abutment interface",
          "why": "A worn or damaged screw thread will loosen again even after a correct retorque; catching it now avoids a repeat visit."
        },
        {
          "detail": "Look up the manufacturer's torque value for the implant/abutment system in use and torque the screw to that exact value with a calibrated torque driver.\n\nWhy: Under-torquing invites another loosening episode; over-torquing can fracture the screw or abutment — the manufacturer value is the only safe reference.\n\nRecord: Torque value applied, screw system, and date — patient chart",
          "id": "s7",
          "kind": "step",
          "materials": [
            "implant torque driver/wrench",
            "manufacturer torque specification sheet"
          ],
          "role": "dentist",
          "title": "Retorque the screw to the manufacturer's specified value",
          "why": "Under-torquing invites another loosening episode; over-torquing can fracture the screw or abutment — the manufacturer value is the only safe reference."
        },
        {
          "detail": "Place PTFE tape or cotton pellet over the screw head, then seal the access hole with composite, contoured and polished to the occlusal anatomy.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "access-hole filling material (PTFE tape + composite)"
          ],
          "role": "dentist",
          "title": "Fill the screw access hole"
        },
        {
          "detail": "Have the patient bite on articulating paper in centric and excursive movements; adjust any heavy contact that could have contributed to the loosening.\n\nWhy: An occlusal high spot or excursive interference is a common root cause of screw loosening, so leaving it unadjusted invites a repeat visit.",
          "id": "s9",
          "kind": "step",
          "materials": [
            "occlusal articulating paper"
          ],
          "role": "dentist",
          "title": "Check and adjust occlusion",
          "why": "An occlusal high spot or excursive interference is a common root cause of screw loosening, so leaving it unadjusted invites a repeat visit."
        },
        {
          "detail": "Explain what was done, advise the patient to call promptly if the restoration feels loose or different again, and confirm any diet restriction for the cement set time.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Give the patient home-care and follow-up instructions"
        },
        {
          "detail": "Chart the mobility finding, whether screw-retained or cement-retained, torque value or cement used, occlusal adjustment made, and patient instructions given.\n\nRecord: Mobility finding, repair method, materials, occlusal adjustment — patient chart",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the visit"
        },
        {
          "detail": "Loose implant restoration resolved",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Loose implant restoration resolved"
        },
        {
          "detail": "Stop this protocol; hand the case to the early implant failure and removal protocol (impl-011) rather than retorquing a mobile fixture.\n\nWhy: Retorquing or reloading a mobile implant fixture can worsen bone loss; it needs its own diagnostic and removal-or-salvage decision.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Reroute to the early implant failure protocol",
          "why": "Retorquing or reloading a mobile implant fixture can worsen bone loss; it needs its own diagnostic and removal-or-salvage decision."
        },
        {
          "detail": "Case rerouted to early implant failure protocol",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Case rerouted to early implant failure protocol"
        },
        {
          "detail": "Check the abutment is still torqued to spec and the crown margin is intact; if the abutment itself is loose, treat it as a screw case and retorque before recementing.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Inspect the abutment and crown fit for a cement-retained restoration"
        },
        {
          "detail": "Clean the internal crown surface and abutment, apply implant-appropriate cement in a thin even layer, seat fully, and remove excess cement completely from around the margin.\n\nWhy: Residual subgingival cement is a documented cause of peri-implant disease, so complete cement cleanup is not optional.",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Recement the crown",
          "why": "Residual subgingival cement is a documented cause of peri-implant disease, so complete cement cleanup is not optional."
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Loose implant crown or abutment screw — retorque and reseal — A patient reports a wobbly implant crown.",
      "title": "Loose implant crown or abutment screw — retorque and reseal",
      "trigger": "A patient reports a wobbly implant crown",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        },
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "impl-011",
      "kind": "clinical",
      "materials": [
        "periapical/bitewing imaging system",
        "local anesthetic kit",
        "implant removal instrument set",
        "bone graft material (if immediate grafting planned)",
        "informed consent form for removal",
        "emergency kit (oxygen, emergency medications)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "If a medical emergency occurs at any point during this procedure, call 911 / activate EMS immediately and begin the office's medical emergency response before anything else. Before any removal instrument contacts the patient, dentist confirms the emergency kit, oxygen, and emergency contact protocol are in place.\n\nWhy: Implant removal is an invasive surgical procedure under local anesthetic carrying the same category of medical-emergency risk (bleeding, syncope, allergic reaction) as placement surgery.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm emergency response readiness before beginning removal.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm emergency response readiness before beginning removal",
          "why": "Implant removal is an invasive surgical procedure under local anesthetic carrying the same category of medical-emergency risk (bleeding, syncope, allergic reaction) as placement surgery."
        },
        {
          "detail": "Ask when the implant was placed or loaded, and whether the patient reports pain, mobility, swelling, or a bad taste/odor at the site.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Assess the reported symptoms and timeline"
        },
        {
          "detail": "Test the implant fixture for mobility (not just the restoration), check for suppuration, swelling, and tenderness to percussion.\n\nWhy: True fixture mobility (as opposed to a loose screw or crown) confirms failed or failing osseointegration and changes the whole plan.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Clinical exam for mobility and infection signs",
          "why": "True fixture mobility (as opposed to a loose screw or crown) confirms failed or failing osseointegration and changes the whole plan."
        },
        {
          "detail": "Capture a current image and compare to the post-placement radiograph for peri-implant radiolucency or crestal bone loss.\n\nRecord: Radiograph and bone-loss comparison — patient chart",
          "id": "s4",
          "kind": "step",
          "materials": [
            "periapical/bitewing imaging system"
          ],
          "role": "dentist",
          "title": "Take a periapical radiograph of the implant"
        },
        {
          "detail": "Weigh mobility, radiolucency extent, infection signs, and whether the implant is loaded or still healing.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "salvageable",
              "label": "No fixture mobility, early mucositis-level finding only"
            },
            {
              "goto": "s9",
              "id": "failed",
              "label": "Fixture is mobile or radiolucency circles the implant — failure confirmed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "How severe is the failure?"
        },
        {
          "detail": "Address the underlying cause found (occlusal overload, hygiene, screw issue), schedule a short-interval recheck, and document a monitoring plan.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Manage conservatively and monitor"
        },
        {
          "detail": "Chart findings, cause addressed, and the recheck date.\n\nRecord: Conservative management plan and recheck date — patient chart",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the conservative plan"
        },
        {
          "detail": "Case resolved with conservative monitoring",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Case resolved with conservative monitoring"
        },
        {
          "detail": "Explain the failure finding, the removal or referral options, and risks to the patient in plain language; obtain signed informed consent before any removal procedure or referral handoff.\n\nWhy: Removal is an irreversible surgical step with alternatives (referral for salvage attempt); the patient must consent to the specific path taken.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent for implant removal or referral.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "materials": [
            "informed consent form for removal"
          ],
          "role": "dentist",
          "title": "Consent for implant removal or referral",
          "why": "Removal is an irreversible surgical step with alternatives (referral for salvage attempt); the patient must consent to the specific path taken."
        },
        {
          "detail": "Weigh case complexity (proximity to nerve/sinus, extent of bone loss, need for grafting) against the treating dentist's scope and comfort.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "refer",
              "label": "Complex case — refer to a specialist"
            },
            {
              "goto": "s13",
              "id": "in-house",
              "label": "Straightforward removal within scope — proceed in-house"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Remove in-house or refer to a specialist?"
        },
        {
          "detail": "Send the specialist referral letter with radiographs, exam findings, and the timeline of symptoms; schedule the patient's specialist appointment before they leave.\n\nRecord: Referral letter sent with radiographs and findings — patient chart",
          "id": "s11",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Refer to a specialist for removal and site management"
        },
        {
          "detail": "Case referred to a specialist",
          "id": "s12",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Case referred to a specialist"
        },
        {
          "detail": "Administer local anesthetic, remove the implant fixture using the appropriate removal instrument (counter-torque or trephine per system), and debride the socket of granulation tissue.",
          "id": "s13",
          "kind": "step",
          "materials": [
            "local anesthetic kit",
            "implant removal instrument set"
          ],
          "role": "dentist",
          "title": "Remove the failed implant"
        },
        {
          "detail": "Decide based on socket wall integrity and infection status whether to graft immediately or let the site heal before a future graft.",
          "forks": [
            {
              "advised": true,
              "goto": "s15",
              "id": "graft-now",
              "label": "Walls intact, no active infection — graft now"
            },
            {
              "goto": "s16",
              "id": "wait",
              "label": "Infection present or walls compromised — let the site heal first"
            }
          ],
          "id": "s14",
          "kind": "fork",
          "role": "dentist",
          "title": "Graft the site now or wait?"
        },
        {
          "detail": "Place bone graft material into the debrided socket per the material's instructions for use, and cover as indicated.",
          "id": "s15",
          "kind": "step",
          "materials": [
            "bone graft material (if immediate grafting planned)"
          ],
          "role": "dentist",
          "title": "Graft the extraction/removal site"
        },
        {
          "detail": "Explain bleeding control, diet restrictions, pain management, and warning signs that need a callback.",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Chart the removal procedure, whether grafted, materials used, and post-op instructions given.\n\nRecord: Removal procedure, graft status, materials, post-op instructions — patient chart",
          "id": "s17",
          "kind": "step",
          "role": "dentist",
          "title": "Document the removal"
        },
        {
          "detail": "Wait the practice's default healing interval before discussing a re-plan for future implant or alternative restoration.\n\nWhy: Attempting to re-plan before the site has healed risks planning against tissue that will still change shape.",
          "id": "s18",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 7776000,
          "title": "Wait for site healing before re-planning",
          "why": "Attempting to re-plan before the site has healed risks planning against tissue that will still change shape."
        },
        {
          "detail": "Schedule the patient for a re-plan consultation once healing is confirmed, covering implant retry, alternative restoration options, and updated cost.",
          "id": "s19",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to treatment coordination for a re-plan consult"
        },
        {
          "detail": "Implant removed and re-plan scheduled",
          "id": "s20",
          "kind": "step",
          "role": "dentist",
          "title": "Implant removed and re-plan scheduled"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Early implant failure — mobility, pain, removal and re-plan — An implant is mobile or painful before or after loading.",
      "title": "Early implant failure — mobility, pain, removal and re-plan",
      "trigger": "An implant is mobile or painful before or after loading",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "source": "FDA implant device labeling / instructions for use (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "open_standard",
          "label": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
          "repaired": {
            "action": "replace",
            "evidence": "Confirmed via independent search (Wiley Online Library record for the same DOI, and the paper's own text): 'Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions... addressing focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies... Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.' Published J Periodontol 2018;89(Suppl 1):S313-S318, DOI 10.1002/JPER.17-0739 — this resolves to the actual consensus-report document the label has always described.",
            "ticket": "PROT-017",
            "was": {
              "source": "AAP/EFP 2017 World Workshop peri-implant disease classification — diagnostic criteria for peri-implant health, mucositis, and peri-implantitis (maintenance/recall and failure assessment only; not a surgical, prosthetic, or planning protocol)",
              "url": "https://doi.org/10.1002/JPER.16-0700"
            }
          },
          "source": "Berglundh T, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89(Suppl 1):S313-S318.",
          "url": "https://doi.org/10.1002/JPER.17-0739"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis)"
        }
      ],
      "class": "implant-surgery-prosthetics",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "impl-012",
      "kind": "clinical",
      "materials": [
        "periapical/bitewing imaging system",
        "depth gauge / stopper drills",
        "CBCT reference images",
        "sinus perforation management kit",
        "informed consent / incident documentation form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Withdraw the drill and pause the procedure the moment depth, resistance change, or bleeding suggests proximity to the nerve canal or sinus floor.\n\nWhy: Continuing to drill past a suspected nerve or sinus boundary risks permanent paresthesia or a larger sinus perforation — stopping first is the only reversible choice available.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Stop the osteotomy drill sequence immediately",
          "why": "Continuing to drill past a suspected nerve or sinus boundary risks permanent paresthesia or a larger sinus perforation — stopping first is the only reversible choice available."
        },
        {
          "detail": "Compare the measured or estimated drill depth against the pre-operative CBCT-planned safety margin to the nerve canal or sinus floor for this site.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "CBCT reference images",
            "depth gauge / stopper drills"
          ],
          "role": "dentist",
          "title": "Cross-check current depth against the CBCT plan"
        },
        {
          "detail": "Determine whether the drill stayed within the planned safety margin, encroached on the nerve canal, or perforated the sinus floor.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "within-margin",
              "label": "Depth still within the planned safety margin — false alarm"
            },
            {
              "goto": "s7",
              "id": "nerve-encroachment",
              "label": "Nerve canal proximity or encroachment suspected"
            },
            {
              "goto": "s14",
              "id": "sinus-perforation",
              "label": "Sinus floor perforation confirmed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "What did the depth check show?"
        },
        {
          "detail": "Continue the sequence using the confirmed depth, re-verifying with the depth gauge at each drill step.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Resume the osteotomy with the confirmed safe depth"
        },
        {
          "detail": "Note that a depth concern arose, was checked against CBCT, and confirmed within margin.\n\nRecord: Depth check finding and resolution — patient chart",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the depth check"
        },
        {
          "detail": "Placement completed, no encroachment confirmed",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Placement completed, no encroachment confirmed"
        },
        {
          "detail": "Ask the patient about any sensation change in the lip, chin, or tongue while still numb only from local anesthetic delivered before drilling, and note baseline for later comparison.\n\nWhy: A same-visit baseline is the only way to later distinguish a true nerve injury from expected local-anesthetic numbness.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Assess neurosensory status intraoperatively",
          "why": "A same-visit baseline is the only way to later distinguish a true nerve injury from expected local-anesthetic numbness."
        },
        {
          "detail": "Decide the safest path based on remaining bone height and the site's restorative requirements.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "shorten",
              "label": "Use a shorter implant maintaining the safety margin"
            },
            {
              "goto": "s16",
              "id": "abort",
              "label": "Abort placement at this site — margin cannot be maintained"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Shorten the implant, relocate the osteotomy, or abort placement?"
        },
        {
          "detail": "Place the shorter or repositioned implant, re-confirming depth against the safety margin before final seating.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Complete placement with the modified plan"
        },
        {
          "detail": "Once the patient is comfortable to communicate (post-anesthesia as needed), explain in plain language what happened, what was done, and what follow-up is planned, and answer questions before they leave.\n\nWhy: An intraoperative complication requires direct disclosure to the patient as part of informed, ongoing consent — this is not optional and not delegable to a later visit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the intraoperative finding to the patient.",
            "type": "safety"
          },
          "id": "s10",
          "kind": "gate",
          "materials": [
            "informed consent / incident documentation form"
          ],
          "role": "dentist",
          "title": "Disclose the intraoperative finding to the patient",
          "why": "An intraoperative complication requires direct disclosure to the patient as part of informed, ongoing consent — this is not optional and not delegable to a later visit."
        },
        {
          "detail": "Chart the finding, the modification or abort decision made, disclosure conversation, and any referral, with timestamps.\n\nRecord: Intraoperative finding, modification/abort decision, disclosure note, referral if any — patient chart",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the incident in full"
        },
        {
          "detail": "Book a follow-up check within the practice's default short interval to reassess neurosensory status or sinus symptoms.",
          "id": "s12",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 604800,
          "title": "Schedule a short-interval follow-up"
        },
        {
          "detail": "Incident documented and follow-up scheduled",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Incident documented and follow-up scheduled"
        },
        {
          "detail": "Assess perforation size; for a small perforation, place a resorbable membrane and consider a shorter implant or staged approach per the sinus perforation management kit's protocol.",
          "id": "s14",
          "kind": "step",
          "materials": [
            "sinus perforation management kit"
          ],
          "role": "dentist",
          "title": "Manage the sinus perforation"
        },
        {
          "detail": "Is the perforation small and manageable in-house, or large?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "manageable",
              "label": "Small perforation — manage and complete or stage in-house"
            },
            {
              "goto": "s17",
              "id": "large",
              "label": "Large perforation — refer for specialist management"
            }
          ],
          "id": "s15",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the perforation small and manageable in-house, or large?"
        },
        {
          "detail": "Close the surgical site per standard closure technique and plan to revisit the site restoratively once healed.",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Close the site without placing an implant"
        },
        {
          "detail": "Close the site as needed, send referral documentation with imaging and the intraoperative finding, and schedule the specialist visit before the patient leaves.",
          "id": "s17",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Refer to a specialist for sinus management"
        }
      ],
      "subclass": "implant-surgery-and-prosthetics",
      "summary": "Intraoperative nerve proximity or sinus perforation during osteotomy — Drill depth reaches the nerve canal or sinus floor during placement.",
      "title": "Intraoperative nerve proximity or sinus perforation during osteotomy",
      "trigger": "Drill depth reaches the nerve canal or sinus floor during placement",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "Weekly count cadence, par-level worksheet and per-operatory stock checklist: (no public standard sets a cadence or par formula) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Weekly count cadence, par-level worksheet and per-operatory stock checklist: generic functional equivalent (no public standard sets a cadence or par formula)"
          },
          "source": "Weekly count cadence, par-level worksheet and per-operatory stock checklist: (no public standard sets a cadence or par formula) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 60,
      "frequency": "weekly",
      "id": "inv-001",
      "kind": "operational",
      "materials": [
        "par level sheet or inventory system",
        "barcode scanner (if used)",
        "count clipboard/tablet",
        "operatory stock checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Assistant or office manager opens the master item list with current par (minimum) and reorder quantities for every stocked item.\n\nWhy: Counting without a reference list produces numbers with nothing to compare against.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current par-level sheet or inventory system export",
          "why": "Counting without a reference list produces numbers with nothing to compare against."
        },
        {
          "detail": "Physically count or scan every item in the central storage area: consumables, PPE, disposables, restorative materials, sundries. Record actual on-hand quantity next to the par figure for each line.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Count central storage / supply room stock"
        },
        {
          "detail": "Walk each operatory and count the working stock kept chairside (gloves, gauze, anesthetic setups, burs, impression material) against the per-operatory par level, separately from central storage.\n\nWhy: Chairside stock depletes on a different rhythm than central storage and can run out mid-procedure if not tracked separately.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Count per-operatory stock in each treatment room",
          "why": "Chairside stock depletes on a different rhythm than central storage and can run out mid-procedure if not tracked separately."
        },
        {
          "detail": "Compare counted quantities to the par sheet; mark each item that is at or below par with the quantity needed to bring it back to target stock.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag every item at or below its par level"
        },
        {
          "detail": "A discrepancy beyond normal use variance (e.g. large unexplained shortage, or a controlled item mismatch) needs investigation before reorder proceeds normally.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "normal",
              "label": "Counts are within normal variance"
            },
            {
              "goto": "s9",
              "id": "flag",
              "label": "Unexplained shortage or overage found"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Large or unexplained discrepancy between counted and system quantity?"
        },
        {
          "detail": "Enter counted quantities and the below-par flag list into the inventory system or shared log, dated and initialed.\n\nRecord: count date, counted quantities per item, below-par flags, any discrepancy note",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the completed count and below-par list"
        },
        {
          "detail": "Office manager passes the flagged below-par item list into the reorder-and-purchase-approval protocol for the same day or next business day.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the below-par list to the reorder step"
        },
        {
          "detail": "Weekly count complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Weekly count complete"
        },
        {
          "detail": "Office manager checks recent orders received, usage logs, and whether the item is tracked separately (e.g. controlled substances follow the prescribing class's own log). Note the finding.\n\nWhy: An unexplained shortage can indicate a receiving error, miscount, or a loss that needs a different response than a routine reorder.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Investigate the discrepancy before closing the count",
          "why": "An unexplained shortage can indicate a receiving error, miscount, or a loss that needs a different response than a routine reorder."
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Weekly inventory count against par levels (including per-operatory stock) — Weekly on a fixed day.",
      "title": "Weekly inventory count against par levels (including per-operatory stock)",
      "trigger": "Weekly on a fixed day",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt) — governs whether a newly ordered chemical product requires an SDS handoff at receipt",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt) — governs whether a newly ordered chemical product requires an SDS handoff at receipt",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "Purchase-approval dollar thresholds and vendor-selection workflow: (a business-controls practice, not a regulatory requirement) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Purchase-approval dollar thresholds and vendor-selection workflow: generic functional equivalent (a business-controls practice, not a regulatory requirement)"
          },
          "source": "Purchase-approval dollar thresholds and vendor-selection workflow: (a business-controls practice, not a regulatory requirement) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "inv-002",
      "kind": "operational",
      "materials": [
        "below-par item list",
        "approved vendor list",
        "purchase approval threshold table"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Office manager reviews either the below-par list from the weekly count or a one-off purchase request submitted by a team member.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the reorder trigger"
        },
        {
          "detail": "Routine restock = items already on the approved par list at their usual quantity. Non-routine = new item type, unusual quantity, or equipment purchase.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "routine",
              "label": "Routine restock of a par-list item"
            },
            {
              "goto": "s8",
              "id": "nonroutine",
              "label": "Non-routine or new item type"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a routine restock or a non-routine purchase?"
        },
        {
          "detail": "Compare the total order cost to the dollar threshold the practice has set for office-manager sign-off versus owner sign-off.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "under",
              "label": "Under threshold"
            },
            {
              "goto": "s9",
              "id": "over",
              "label": "At or above threshold"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the order total exceed the pre-set approval threshold?"
        },
        {
          "detail": "Order from the approved vendor list at the negotiated price; if the preferred vendor is out of stock, check the secondary vendor before ordering elsewhere.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Select vendor and place the order"
        },
        {
          "detail": "Note the confirmed or estimated delivery date so receiving staff know when to expect the shipment.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm expected delivery window"
        },
        {
          "detail": "Enter vendor, items, quantities, total cost, approval basis (routine/threshold/owner), and expected delivery date into the purchasing log.\n\nRecord: vendor, items ordered, cost, approval trail, expected delivery date",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the order"
        },
        {
          "detail": "Order placed and logged",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Order placed and logged"
        },
        {
          "detail": "Office manager summarizes what is requested, why, estimated cost, and vendor, and sends it to the practice owner before ordering.\n\nWhy: New item types and unusual purchases fall outside the pre-approved routine budget and need a specific decision.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Route non-routine purchase to the practice owner for review",
          "why": "New item types and unusual purchases fall outside the pre-approved routine budget and need a specific decision."
        },
        {
          "detail": "Order does not proceed until the practice owner (or named delegate) approves the total spend.\n\nWhy: Spend above the set threshold is a money decision reserved for the practice owner, not delegated to routine staff judgment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off required for above-threshold purchase.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off required for above-threshold purchase",
          "why": "Spend above the set threshold is a money decision reserved for the practice owner, not delegated to routine staff judgment."
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Reorder trigger and purchase-approval thresholds — An item falls below par or a non-routine purchase is requested.",
      "title": "Reorder trigger and purchase-approval thresholds",
      "trigger": "An item falls below par or a non-routine purchase is requested",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "Receiving checklist and put-away shelving practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Receiving checklist and put-away shelving practice: generic functional equivalent"
          },
          "source": "Receiving checklist and put-away shelving practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "inv-003",
      "kind": "operational",
      "materials": [
        "packing slip / purchase order",
        "inventory system or log",
        "storage area with labeled shelving"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Sign for the delivery if required, and pull the packing slip or invoice that lists what should be inside.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Accept the delivery and locate the packing slip"
        },
        {
          "detail": "Open the shipment and verify each item, quantity, and lot/expiration where visible, against the packing slip and the order placed.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Check contents against the packing slip and original purchase order"
        },
        {
          "detail": "Check packaging for damage, and check any temperature-sensitive items (refrigerated materials) for signs the cold chain was broken (warm to touch, indicator strip out of range).\n\nWhy: A damaged or temperature-compromised item can be unsafe to use even though it visually matches the order.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Inspect for damage or temperature excursion",
          "why": "A damaged or temperature-compromised item can be unsafe to use even though it visually matches the order."
        },
        {
          "detail": "Decide whether the shipment matches the order in full good condition with no cold-chain excursion, or needs a vendor claim.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "clean",
              "label": "Order matches, no damage, no temperature excursion"
            },
            {
              "goto": "s9",
              "id": "issue",
              "label": "Shortage, damage, wrong item, or temperature excursion"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Shortage, damage, wrong item, or temperature excursion found?"
        },
        {
          "detail": "Check whether any item is new to the practice's product list (new disinfectant, new material, new chemical).",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "none-new",
              "label": "No new chemical products"
            },
            {
              "goto": "s10",
              "id": "new-product",
              "label": "New chemical product included"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the shipment include any chemical product not previously stocked?"
        },
        {
          "detail": "Stock items in their labeled shelf location, rotating stock so older expiration dates sit in front (first-expired, first-out).\n\nWhy: Stock rotation keeps short-dated items from being buried and expiring unused.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Put items away in their designated storage location",
          "why": "Stock rotation keeps short-dated items from being buried and expiring unused."
        },
        {
          "detail": "Update on-hand quantities in the inventory system or log, noting receipt date, any claim filed, and any new-product SDS handoff.\n\nRecord: items received, quantities, receipt date, claim status, new-product flag",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the receipt in the inventory system"
        },
        {
          "detail": "Order received, checked, and put away",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Order received, checked, and put away"
        },
        {
          "detail": "Photograph the issue, note it against the packing slip, and contact the vendor for a replacement or credit. Set the affected item aside, unused, until resolved.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "File a vendor claim and hold the affected items"
        },
        {
          "detail": "Set the new product aside labeled and notify the compliance officer that a new chemical product has arrived, so it is entered into the hazard-communication inventory before general use.\n\nWhy: OSHA Hazard Communication requires an SDS be on file and accessible before staff use a new hazardous chemical.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the new product to the SDS filing protocol",
          "why": "OSHA Hazard Communication requires an SDS be on file and accessible before staff use a new hazardous chemical."
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Receiving, checking and putting away an order — A delivery arrives.",
      "title": "Receiving, checking and putting away an order",
      "trigger": "A delivery arrives",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt, accessible to employees)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt, accessible to employees)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "inv-004",
      "kind": "operational",
      "materials": [
        "safety data sheet (SDS) from manufacturer or supplier",
        "hazard-communication binder or digital SDS library",
        "chemical inventory list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Request or download the SDS from the manufacturer or vendor if it did not arrive with the shipment; most vendors provide it on their website or on request.\n\nWhy: OSHA Hazard Communication requires an SDS be available for every hazardous chemical in the workplace.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Obtain the Safety Data Sheet for the new product",
          "why": "OSHA Hazard Communication requires an SDS be available for every hazardous chemical in the workplace."
        },
        {
          "detail": "Read the SDS sections for hazard classification, required personal protective equipment, first-aid measures, and storage requirements.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review the hazard classification and required PPE"
        },
        {
          "detail": "Check whether the SDS storage section flags flammability, refrigeration, or chemical incompatibility with items already on hand.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "standard",
              "label": "Standard storage is fine"
            },
            {
              "goto": "s8",
              "id": "special",
              "label": "Special storage required"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the product require special storage (flammable, refrigerated, incompatible with another stocked chemical)?"
        },
        {
          "detail": "Add the SDS to the practice's SDS binder or digital library so it is accessible to all staff during working hours.\n\nRecord: product name, SDS filed date, storage requirements noted",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the SDS in the hazard-communication binder or digital library"
        },
        {
          "detail": "Add the product name and location to the practice's master chemical inventory list, as required by the hazard communication standard.\n\nRecord: chemical inventory list entry: product name, storage location, date added",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the written chemical inventory list"
        },
        {
          "detail": "Brief the team members who will use or be near the product on any hazard, required PPE, or first-aid measure that differs from products already in use.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify staff who will handle the product of any new hazard or PPE requirement"
        },
        {
          "detail": "SDS filed and hazard-communication inventory current",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "SDS filed and hazard-communication inventory current"
        },
        {
          "detail": "Relocate the product to the appropriate storage (flammable cabinet, refrigeration, separated from an incompatible chemical) and label accordingly.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Arrange the required special storage before general use"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "New chemical product — SDS filed and hazard-communication inventory updated — A product not previously stocked arrives.",
      "title": "New chemical product — SDS filed and hazard-communication inventory updated",
      "trigger": "A product not previously stocked arrives",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR Part 1304 records (controlled-substance stock is handled in the prescribing class)",
          "source": "DEA 21 CFR Part 1304 records (controlled-substance stock is handled in the prescribing class)",
          "url": "https://www.ecfr.gov/current/title-21/part-1304"
        },
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "Emergency kit contents — reuse DOCS/TECHNICAL_PROTOCOLS.md §7.2",
          "source": "Emergency kit contents — reuse DOCS/TECHNICAL_PROTOCOLS.md §7.2"
        },
        {
          "kind": "generic",
          "label": "Monthly sweep cadence and pharmaceutical waste segregation bins: generic functional equivalent; local/state pharmaceutical and biohazard waste rules vary and should be confirmed with the practice's waste hauler",
          "source": "Monthly sweep cadence and pharmaceutical waste segregation bins: generic functional equivalent; local/state pharmaceutical and biohazard waste rules vary and should be confirmed with the practice's waste hauler"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 45,
      "frequency": "monthly",
      "id": "inv-005",
      "kind": "operational",
      "materials": [
        "expiration sweep checklist",
        "pharmaceutical waste container (segregated, hazardous vs non-hazardous)",
        "sharps container"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Assistant gathers the checklist covering central storage, each operatory, the refrigerator, and the emergency kit.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Pull the expiration sweep checklist covering all storage areas"
        },
        {
          "detail": "Physically check the printed expiration date on every restorative material, impression material, and local anesthetic cartridge in stock and chairside.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Check restorative materials and anesthetic cartridges for expiration"
        },
        {
          "detail": "Check expiration on non-controlled drugs in stock and every item in the emergency kit (epinephrine autoinjector, nitroglycerin, aspirin, diphenhydramine, albuterol inhaler, oral glucose), and verify the emergency kit's O2 gauge reading and AED pads/battery status as part of the same monthly check.\n\nWhy: An expired emergency drug can fail exactly when it is needed most; the practice's own emergency protocol requires this check monthly.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Check non-controlled drugs and emergency kit contents for expiration",
          "why": "An expired emergency drug can fail exactly when it is needed most; the practice's own emergency protocol requires this check monthly."
        },
        {
          "detail": "Controlled substances are logged and disposed of under DEA 21 CFR Part 1304 recordkeeping, which the prescribing class's protocol handles separately.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "none",
              "label": "No controlled substances involved"
            },
            {
              "goto": "s11",
              "id": "controlled",
              "label": "Controlled substance found expired/near-expiring"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Does any expired or near-expiring item include a controlled substance?"
        },
        {
          "detail": "Remove every expired item from where staff would reach for it, and set aside in a clearly marked 'expired — do not use' area.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Pull all expired items from active stock"
        },
        {
          "detail": "The dentist reviews the pulled-expired list, confirms nothing on it was already used, and signs off before disposal proceeds.\n\nWhy: Clinical materials and drugs carry patient-safety consequences; discard of clinical stock is a licensed sign-off step, not a routine housekeeping decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off before discarding clinical materials.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off before discarding clinical materials",
          "why": "Clinical materials and drugs carry patient-safety consequences; discard of clinical stock is a licensed sign-off step, not a routine housekeeping decision."
        },
        {
          "detail": "Sort expired items into the correct waste stream (hazardous pharmaceutical waste, non-hazardous pharmaceutical waste, sharps) per the practice's waste hauler categories; never discard pharmaceutical waste down a drain or in general trash.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Segregate pharmaceutical waste by category before disposal"
        },
        {
          "detail": "Any item removed for expiration that is now below par is added to the below-par list and handed to the reorder-and-purchase-approval protocol.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Flag removed items for the reorder protocol"
        },
        {
          "detail": "Record sweep date, items found expired, dentist sign-off, and waste disposal method.\n\nRecord: sweep date, expired items list, dentist sign-off, disposal category",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Log the sweep results"
        },
        {
          "detail": "Monthly expiration sweep complete",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Monthly expiration sweep complete"
        },
        {
          "detail": "Note the item and quantity, and hand off to the practice's controlled-substance disposal process rather than discarding it through this sweep.\n\nWhy: Controlled substances require DEA-compliant reverse distribution or witnessed destruction, distinct from ordinary pharmaceutical waste.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Route controlled-substance expirations to the DEA recordkeeping protocol",
          "why": "Controlled substances require DEA-compliant reverse distribution or witnessed destruction, distinct from ordinary pharmaceutical waste."
        },
        {
          "detail": "Record which controlled item(s) were routed out of this sweep, the quantity, and the date handed to the controlled-substance disposal process, so this sweep's own log does not also claim to have disposed of them.\n\nRecord: item, quantity, date routed to controlled-substance disposal process",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the controlled-substance handoff and exit this sweep for those items"
        },
        {
          "detail": "Controlled-substance expirations routed to DEA-compliant disposal (outside this sweep)",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Controlled-substance expirations routed to DEA-compliant disposal (outside this sweep)"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Monthly expiration-date sweep (materials, anesthetics, non-controlled drugs) and pharmaceutical waste segregation — The first week of the month, or a product with a short shelf life is opened.",
      "title": "Monthly expiration-date sweep (materials, anesthetics, non-controlled drugs) and pharmaceutical waste segregation",
      "trigger": "The first week of the month, or a product with a short shelf life is opened",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA dental devices 21 CFR Part 872 general device clearance framework — a substitute material/device remains subject to the same clearance context as the item it replaces",
          "source": "FDA dental devices 21 CFR Part 872 general device clearance framework — a substitute material/device remains subject to the same clearance context as the item it replaces",
          "url": "https://www.ecfr.gov/current/title-21/part-872"
        },
        {
          "kind": "generic",
          "label": "Substitute-material clinical approval workflow — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Substitute-material clinical approval workflow: generic functional equivalent"
          },
          "source": "Substitute-material clinical approval workflow — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "inv-006",
      "kind": "operational",
      "materials": [
        "backorder notice from distributor",
        "alternate vendor list",
        "material safety/compatibility reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "office-manager",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager confirms with the distributor which item, how much stock remains on hand, and the expected restock date.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the backorder scope and expected resolution date"
        },
        {
          "detail": "Compare remaining stock against the schedule's expected usage rate through the expected restock date.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "sufficient",
              "label": "Remaining stock covers the gap"
            },
            {
              "goto": "s5",
              "id": "insufficient",
              "label": "Remaining stock will run out before restock"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Will remaining on-hand stock cover the schedule until restock?"
        },
        {
          "detail": "Record the backordered item, expected restock date, substitute decision (if any) and dentist sign-off, and affected appointments.\n\nRecord: backordered item, restock date, substitute decision, dentist sign-off, affected appointments",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the backorder event and resolution"
        },
        {
          "detail": "Backorder response logged",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Backorder response logged"
        },
        {
          "detail": "Check the alternate vendor list for the same product from a different distributor before considering a different product.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Search alternate vendors for the identical item"
        },
        {
          "detail": "If the identical product is sourced elsewhere, no clinical substitution decision is needed — only a purchasing decision.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "found",
              "label": "Identical item found elsewhere"
            },
            {
              "goto": "s8",
              "id": "not-found",
              "label": "No source for the identical item"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was the identical item found through an alternate vendor?"
        },
        {
          "detail": "Hand off to the reorder-and-purchase-approval protocol to place the order through the alternate vendor.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Route the alternate-vendor order to the purchase-approval protocol"
        },
        {
          "detail": "Office manager or clinical team identifies a comparable material available in stock or quickly sourceable, and notes its indications and any known differences from the backordered item.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify a candidate substitute material"
        },
        {
          "detail": "The dentist reviews the proposed substitute material for clinical appropriateness and approves, modifies, or rejects it before it enters chairside use.\n\nWhy: Swapping a clinical material without a licensed clinician's review risks a mismatch in indication, technique, or patient compatibility.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist approves the clinical substitute before it is used on patients.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist approves the clinical substitute before it is used on patients",
          "why": "Swapping a clinical material without a licensed clinician's review risks a mismatch in indication, technique, or patient compatibility."
        },
        {
          "detail": "Record the dentist's decision on the proposed substitute.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "approved",
              "label": "Substitute approved for use"
            },
            {
              "goto": "s12",
              "id": "rejected",
              "label": "Substitute rejected — reschedule affected cases instead"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Did the dentist approve the substitute?"
        },
        {
          "detail": "Notify assistants and the sterilization technician which substitute material is in use, any technique difference, and how long it is expected to remain in use.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Brief the clinical and sterilization team on the approved substitute"
        },
        {
          "detail": "Office manager passes the list of affected appointments to scheduling to rebook once the original item restocks.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand rejected-substitute cases to scheduling for rebooking"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Backorder or critical shortage — substitute material approval — A distributor reports a backorder on a clinical material or a consumable the clinic cannot run without.",
      "title": "Backorder or critical shortage — substitute material approval",
      "trigger": "A distributor reports a backorder on a clinical material or a consumable the clinic cannot run without",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA recall procedures 21 CFR Part 7 — quarantine and disposition of recalled stock",
          "source": "FDA recall procedures 21 CFR Part 7 — quarantine and disposition of recalled stock",
          "url": "https://www.ecfr.gov/current/title-21/part-7"
        },
        {
          "kind": "regulation",
          "label": "FDA voluntary MedWatch adverse-event/device-malfunction reporting (Form 3500), used at the file-medwatch step of this protocol",
          "source": "FDA voluntary MedWatch adverse-event/device-malfunction reporting (Form 3500), used at the file-medwatch step of this protocol",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "inv-007",
      "kind": "operational",
      "materials": [
        "recall notice",
        "lot number traceability log",
        "patient list cross-referenced by lot (if applicable)",
        "MedWatch Form 3500 (voluntary reporting)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Compliance officer logs the recall source (manufacturer letter, FDA notice), product, affected lot number(s), and the reason for recall.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Receive and log the recall notice"
        },
        {
          "detail": "Pull all remaining stock matching the recalled lot number from central storage and every operatory, and place it in a clearly labeled quarantine area, unused, pending disposition instructions.\n\nWhy: Removing recalled stock from circulation immediately prevents further use while the impact is assessed.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Quarantine remaining on-hand stock from the affected lot",
          "why": "Removing recalled stock from circulation immediately prevents further use while the impact is assessed."
        },
        {
          "detail": "Cross-reference the recalled lot number against the lot traceability log to see whether it was placed, implanted, or administered before the recall.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "not-used",
              "label": "No patient use of this lot found"
            },
            {
              "goto": "s8",
              "id": "used",
              "label": "Lot was used on one or more patients"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Was any product from the affected lot already used on a patient?"
        },
        {
          "detail": "If a device malfunction or adverse event is associated with the recalled product, the dentist and compliance officer decide whether to file a voluntary MedWatch Form 3500 report to the FDA.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File a MedWatch report if the event meets voluntary reporting criteria"
        },
        {
          "detail": "Follow the specific return, destruction, or credit instructions in the recall notice for the quarantined stock; do not discard it as routine waste without those instructions.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Dispose of or return quarantined stock per the manufacturer's recall instructions"
        },
        {
          "detail": "Record the recall notice, quarantine action, affected-patient list and dentist review, notification outcomes, MedWatch filing status, and final stock disposition.\n\nRecord: recall details, quarantine log, affected patients and dentist review, notification outcomes, MedWatch status, stock disposition",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the recall response and closure"
        },
        {
          "detail": "Recall response closed",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Recall response closed"
        },
        {
          "detail": "Pull the full list of patients whose record shows the affected lot number, using the implant/device lot traceability records.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify every patient who received product from the affected lot"
        },
        {
          "detail": "The dentist reviews the nature of the recall (the specific defect or hazard) against each affected patient's clinical situation to determine the recommended next step (monitoring, evaluation, or a specific action) before anyone contacts the patient.\n\nWhy: What to tell an affected patient, and what if anything they need to do, is a clinical judgment that must come from the treating dentist, not a scripted office notice.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews clinical risk for each affected patient before contact.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews clinical risk for each affected patient before contact",
          "why": "What to tell an affected patient, and what if anything they need to do, is a clinical judgment that must come from the treating dentist, not a scripted office notice."
        },
        {
          "detail": "Front desk or office manager contacts each affected patient using the dentist-approved guidance, and documents the contact attempt and outcome in the patient's record.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Contact affected patients with the dentist-reviewed guidance"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Manufacturer or FDA recall notice — quarantine, patient impact review and recall reply — A recall notice arrives for a material, device, implant lot or drug in stock or already used.",
      "title": "Manufacturer or FDA recall notice — quarantine, patient impact review and recall reply",
      "trigger": "A recall notice arrives for a material, device, implant lot or drug in stock or already used",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA Medical Device Reporting 21 CFR Part 803 — lot/serial traceability is what makes a device recall or malfunction report actionable back to the specific patient",
          "source": "FDA Medical Device Reporting 21 CFR Part 803 — lot/serial traceability is what makes a device recall or malfunction report actionable back to the specific patient",
          "url": "https://www.ecfr.gov/current/title-21/part-803"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "inv-008",
      "kind": "operational",
      "materials": [
        "device packaging with lot/serial number sticker",
        "patient clinical record",
        "lot traceability log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Assistant confirms the device type, size, and lot/serial number printed on the packaging against what was planned for the case before it is opened and placed.\n\nWhy: Verifying identity before opening catches a wrong-size or wrong-lot device before it is used, not after.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the device package and lot number before opening",
          "why": "Verifying identity before opening catches a wrong-size or wrong-lot device before it is used, not after."
        },
        {
          "detail": "Peel the manufacturer's lot/serial sticker from the device packaging (most implant and graft packaging includes a peel-off traceability label) and set it aside for the chart.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Retain the lot/serial number sticker from the packaging"
        },
        {
          "detail": "Before the device is opened for use, the dentist personally verifies the device type, size, and lot number against the clinical plan and signs off that this is the correct device for this patient.\n\nWhy: A licensed sign-off immediately before an implantable device is placed catches a wrong-device or wrong-lot error before it becomes irreversible.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms device type, size and lot number before placement.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms device type, size and lot number before placement",
          "why": "A licensed sign-off immediately before an implantable device is placed catches a wrong-device or wrong-lot error before it becomes irreversible."
        },
        {
          "detail": "Dentist places the implant, membrane, bone graft, or prosthetic component per the clinical plan.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Device is placed by the dentist"
        },
        {
          "detail": "Attach or scan the lot/serial sticker directly into the patient's chart entry for that date of service, alongside the procedure note.\n\nWhy: Recording the lot number the same day, tied to the specific patient and site, is what makes a future recall traceable to this patient.\n\nRecord: device type, lot/serial number, procedure date, tooth/site, placing dentist",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Affix the lot sticker to the patient's clinical record the same day",
          "why": "Recording the lot number the same day, tied to the specific patient and site, is what makes a future recall traceable to this patient."
        },
        {
          "detail": "Some packaging does not include a peel-off sticker, or one was misplaced during the procedure.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "present",
              "label": "Sticker present and affixed"
            },
            {
              "goto": "s9",
              "id": "missing",
              "label": "Sticker missing or lost"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Is a lot/serial sticker missing from the packaging?"
        },
        {
          "detail": "Add the entry to the practice-wide lot traceability log (device, lot number, patient, date, site) so a future recall can be cross-referenced by lot without searching every chart individually.\n\nRecord: device, lot number, patient reference, procedure date, site",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Update the practice's lot traceability log"
        },
        {
          "detail": "Device lot traceability recorded",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Device lot traceability recorded"
        },
        {
          "detail": "Copy the lot/serial number by hand from the outer packaging into the chart entry before the box is discarded, and note that this was a manual transcription rather than the peel-off sticker.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Manually transcribe the lot number from the outer box before discarding it"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Implant and device lot number traceability in the record — An implant, membrane, bone graft or prosthetic component is placed.",
      "title": "Implant and device lot number traceability in the record",
      "trigger": "An implant, membrane, bone graft or prosthetic component is placed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt, which states storage conditions)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt, which states storage conditions)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "For a daily temperature-log checklist — no vendor logging product named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a daily temperature-log checklist — no vendor logging product named"
          },
          "source": "For a daily temperature-log checklist — no vendor logging product named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 5,
      "frequency": "daily",
      "id": "inv-009",
      "kind": "operational",
      "materials": [
        "min/max thermometer or digital data logger",
        "storage temperature log sheet or app",
        "manufacturer storage requirement labels",
        "backup cooler and ice packs"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "At the daily opening check, read the min/max thermometer or data logger in each unit storing temperature-sensitive product (vaccines are not stocked here, but refrigerated anesthetics, some impression materials, and certain emergency drugs are). Record the current reading, and the min/max since the last check, on the log sheet or app.\n\nWhy: A single spot-check misses an overnight excursion; min/max capture catches it even if the unit has since recovered.\n\nRecord: date, time, unit id, current temp, min/max since last read, initials",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Read and record the refrigerator/freezer temperature",
          "why": "A single spot-check misses an overnight excursion; min/max capture catches it even if the unit has since recovered."
        },
        {
          "detail": "Check the reading against the storage requirement printed on each product's label or SDS — different products in the same unit can have different acceptable ranges.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "in-range",
              "label": "All readings in range"
            },
            {
              "goto": "s5",
              "id": "out-of-range",
              "label": "Any reading out of range, alarm active, or unit was without power"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Is every reading within the manufacturer's stated range for every product stored in that unit?"
        },
        {
          "detail": "Reset the thermometer's min/max memory for the next 24-hour window and sign off the log entry as normal.\n\nWhy: Resetting keeps the next reading meaningful instead of showing a stale extreme from days ago.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Reset the min/max display and close the log entry",
          "why": "Resetting keeps the next reading meaningful instead of showing a stale extreme from days ago."
        },
        {
          "detail": "Daily check complete, all product in range",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Daily check complete, all product in range"
        },
        {
          "detail": "Move or tag every item from the out-of-range unit as \"DO NOT USE — pending review\" and stop dispensing from it immediately, including anything that may have already been pulled for a chair-side setup today.\n\nWhy: Product held outside its stated range may lose potency or become unsafe even though it looks and smells normal.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Physically separate and label all product from the affected unit",
          "why": "Product held outside its stated range may lose potency or become unsafe even though it looks and smells normal."
        },
        {
          "detail": "The dentist reviews the excursion (how far out of range, how long, which products) and decides discard-and-reorder versus, where the manufacturer's own stability data supports it, continued use. Nothing is dispensed from the affected unit until that decision is documented.\n\nWhy: Clinical judgment on whether a temperature excursion actually compromised a product belongs to the licensed clinician, not the front-of-house log-keeper.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Notify the dentist before any quarantined item re-enters use.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "assistant",
          "title": "Notify the dentist before any quarantined item re-enters use",
          "why": "Clinical judgment on whether a temperature excursion actually compromised a product belongs to the licensed clinician, not the front-of-house log-keeper."
        },
        {
          "detail": "Log the full incident on the temperature log with a cross-reference note, and open a maintenance ticket if the unit itself is suspect.\n\nRecord: unit id, duration of excursion, temperature reached, dentist's disposition decision, products discarded (with quantity/value for reorder), repair or replacement ticket number if the unit failed",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Document the excursion and the corrective action"
        },
        {
          "detail": "Add every discarded item to the reorder list so par levels are not silently depleted (feeds the reorder-and-purchase-approval protocol).\n\nWhy: An excursion that goes unrecorded on the reorder list quietly leaves the office short when the item is next needed.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Trigger reorder for any discarded product",
          "why": "An excursion that goes unrecorded on the reorder list quietly leaves the office short when the item is next needed."
        },
        {
          "detail": "Excursion handled, product disposition recorded",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Excursion handled, product disposition recorded"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Temperature-sensitive product storage log (refrigerated materials, emergency drugs) — The daily opening check, or a refrigerator alarm or power outage.",
      "title": "Temperature-sensitive product storage log (refrigerated materials, emergency drugs)",
      "trigger": "The daily opening check, or a refrigerator alarm or power outage",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt identifies latex/allergen content of new products)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt identifies latex/allergen content of new products)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "For a latex-free supply line and chart-flagging workflow — no vendor product line named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a latex-free supply line and chart-flagging workflow — no vendor product line named"
          },
          "source": "For a latex-free supply line and chart-flagging workflow — no vendor product line named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "inv-010",
      "kind": "operational",
      "materials": [
        "latex-free glove and dam supply",
        "allergen product master list",
        "patient chart allergy field",
        "operatory door/chart allergy flag"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "This protocol runs from either direction: a new allergy disclosure, or the periodic reorder cycle checking allergen-aware stock levels.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "patient-allergy",
              "label": "Patient reported a latex, chlorhexidine, or metal allergy"
            },
            {
              "goto": "s7",
              "id": "reorder-cycle",
              "label": "Routine reorder cycle for allergen-aware supplies"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was this triggered by a patient reporting an allergy, or a routine reorder?"
        },
        {
          "detail": "Ask what the allergen is (latex, chlorhexidine, nickel/metal, sulfite in local anesthetic, etc.) and what reaction it causes, since severity changes the response (contact rash versus anaphylaxis risk).\n\nWhy: A vague \"allergic to dental stuff\" note is not actionable; the specific agent determines which products must be substituted.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the specific allergen and reaction type",
          "why": "A vague \"allergic to dental stuff\" note is not actionable; the specific agent determines which products must be substituted."
        },
        {
          "detail": "Enter the allergy in the chart's allergy field so it surfaces automatically on every future visit, not just today's.\n\nRecord: allergen, reaction type, date reported, source (patient self-report)",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the allergy in the patient's chart"
        },
        {
          "detail": "Before the patient is seated, notify the assistant and dentist so latex-free gloves, dam, and any affected materials (e.g., chlorhexidine rinse, certain local anesthetic preservatives) are pulled instead of the standard setup.\n\nWhy: An allergy noted only in the chart after the visit does nothing to protect the patient during today's appointment.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Alert the assistant and dentist for today's appointment",
          "why": "An allergy noted only in the chart after the visit does nothing to protect the patient during today's appointment."
        },
        {
          "detail": "Latex-free gloves on the tray, latex-free dam if a dam is used, allergen-aware barrier and rinse products, and a visible flag on the chart or door per the practice's chosen method.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Verify the operatory is set up allergen-safe before the patient is seated"
        },
        {
          "detail": "Patient allergy flagged and today's operatory set up safely",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Patient allergy flagged and today's operatory set up safely"
        },
        {
          "detail": "During the regular reorder cycle, confirm latex-free alternatives are stocked at the same reliability as standard supplies — an office cannot treat an allergic patient safely if the substitute is out of stock.\n\nWhy: Allergen-aware stock tends to get deprioritized because it moves slower than standard supply; a stockout only surfaces when a flagged patient is in the chair.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Check latex-free glove, dam, and allergen-aware product stock against par",
          "why": "Allergen-aware stock tends to get deprioritized because it moves slower than standard supply; a stockout only surfaces when a flagged patient is in the chair."
        },
        {
          "detail": "Is latex-free/allergen-aware stock below par?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "adequate",
              "label": "Stock is adequate"
            },
            {
              "goto": "s10",
              "id": "below",
              "label": "Below par"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "assistant",
          "title": "Is latex-free/allergen-aware stock below par?"
        },
        {
          "detail": "Allergen-aware stock confirmed adequate",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Allergen-aware stock confirmed adequate"
        },
        {
          "detail": "Feed the shortfall into the reorder-and-purchase-approval protocol, flagged as patient-safety stock rather than routine restock.\n\nWhy: Priority flagging keeps allergen-aware stock from being deferred behind lower-stakes items during a tight ordering month.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Add allergen-aware items to the reorder list with priority",
          "why": "Priority flagging keeps allergen-aware stock from being deferred behind lower-stakes items during a tight ordering month."
        },
        {
          "detail": "Allergen-aware reorder escalated",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Allergen-aware reorder escalated"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Latex-free and allergen-aware product inventory and patient flagging — A patient reports a latex, chlorhexidine or metal allergy, or supplies are reordered.",
      "title": "Latex-free and allergen-aware product inventory and patient flagging",
      "trigger": "A patient reports a latex, chlorhexidine or metal allergy, or supplies are reordered",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA dental devices 21 CFR Part 872 and general device clearance framework (off-label use is a recognized, lawful part of licensed clinical practice but is not an FDA-cleared indication)",
          "source": "FDA dental devices 21 CFR Part 872 and general device clearance framework (off-label use is a recognized, lawful part of licensed clinical practice but is not an FDA-cleared indication)",
          "url": "https://www.ecfr.gov/current/title-21/part-872"
        },
        {
          "kind": "generic",
          "label": "For an off-label-use informed consent process — no institute or vendor protocol reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for an off-label-use informed consent process — no institute or vendor protocol reproduced"
          },
          "source": "For an off-label-use informed consent process — no institute or vendor protocol reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "inv-011",
      "kind": "operational",
      "materials": [
        "FDA clearance/labeling for the device or material",
        "off-label use consent form",
        "chart documentation template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "patient",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the device or material's FDA clearance/labeling (kept on file from receiving, per the SDS/labeling protocol) against the intended clinical use. Off-label use is legal and common in dentistry, but it is a distinct decision that must be made deliberately, not by default.\n\nWhy: Clinicians reach for a familiar material in a new application without always pausing to note it is off-label; naming it explicitly is what triggers the consent and documentation steps below.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify that the proposed use is outside the material or device's cleared indication",
          "why": "Clinicians reach for a familiar material in a new application without always pausing to note it is off-label; naming it explicitly is what triggers the consent and documentation steps below."
        },
        {
          "detail": "Note why the cleared alternative is not being used (unavailable, clinically inferior for this case, cost, patient factor) and what published or accepted clinical basis supports the off-label use.\n\nWhy: A documented rationale is the standard-of-care defense if the choice is ever questioned later; an undocumented one leaves the decision looking arbitrary in hindsight.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Document the clinical rationale",
          "why": "A documented rationale is the standard-of-care defense if the choice is ever questioned later; an undocumented one leaves the decision looking arbitrary in hindsight."
        },
        {
          "detail": "Explain to the patient, in plain language, that the material/device is being used outside its FDA-cleared indication, why, what the alternatives are, and the risks/benefits. Have the patient sign a specific off-label use consent form in addition to the general treatment consent.\n\nWhy: General treatment consent does not cover the specific fact of off-label use; a patient is entitled to know when a product is being used outside its cleared purpose before agreeing to it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain explicit informed consent before proceeding.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain explicit informed consent before proceeding",
          "why": "General treatment consent does not cover the specific fact of off-label use; a patient is entitled to know when a product is being used outside its cleared purpose before agreeing to it."
        },
        {
          "detail": "The compliance officer checks whether this specific off-label use has been reviewed and documented before (a repeat, well-established off-label use in the practice) or is novel.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "established",
              "label": "Established, previously reviewed off-label use"
            },
            {
              "goto": "s7",
              "id": "novel",
              "label": "First-time or unusual off-label use"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does this use fall within the practice's existing off-label policy, or is it a first-time use?"
        },
        {
          "detail": "File the signed consent form and chart note together so the full off-label decision trail is retrievable.\n\nRecord: material/device name and lot, cleared indication vs. actual use, clinical rationale, consent form reference, date, provider",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Record the full encounter in the chart"
        },
        {
          "detail": "Off-label use decision documented and consented",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Off-label use decision documented and consented"
        },
        {
          "detail": "Add the case to the practice's off-label use policy log so the practice owner and compliance officer can decide whether to adopt it as an accepted practice pattern or treat it as an isolated exception.\n\nWhy: Tracking novel off-label decisions in aggregate (not just per-patient) is what lets a practice notice a pattern before it becomes a liability exposure.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the novel off-label use for practice-level review",
          "why": "Tracking novel off-label decisions in aggregate (not just per-patient) is what lets a practice notice a pattern before it becomes a liability exposure."
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Off-label device or material use decision and consent — A clinician proposes using a material outside its cleared indication.",
      "title": "Off-label device or material use decision and consent",
      "trigger": "A clinician proposes using a material outside its cleared indication",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS applies to sample chemical/drug products same as purchased stock)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS applies to sample chemical/drug products same as purchased stock)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR Part 1304 records — applies only if a sample is a controlled substance; most dental samples (rinses, desensitizers, OTC-class products) are not, but the log below is written to cover the controlled case",
          "source": "DEA 21 CFR Part 1304 records — applies only if a sample is a controlled substance; most dental samples (rinses, desensitizers, OTC-class products) are not, but the log below is written to cover the controlled case",
          "url": "https://www.ecfr.gov/current/title-21/part-1304"
        },
        {
          "kind": "generic",
          "label": "For a sample-receipt log — no vendor sample program named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a sample-receipt log — no vendor sample program named"
          },
          "source": "For a sample-receipt log — no vendor sample program named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "inv-012",
      "kind": "operational",
      "materials": [
        "sample log sheet",
        "locked/controlled sample storage area",
        "expiration-tracking calendar"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Only accept samples with intact labeling showing lot number and expiration date. Route the representative and samples to the dentist or designated staff member rather than leaving them at the front desk unlogged.\n\nWhy: Unlabeled or repackaged samples cannot be safely tracked for recalls or expiration, so they should not enter inventory at all.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive the samples from the representative",
          "why": "Unlabeled or repackaged samples cannot be safely tracked for recalls or expiration, so they should not enter inventory at all."
        },
        {
          "detail": "Is the sample a controlled substance?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "not-controlled",
              "label": "Not a controlled substance (rinse, desensitizer, OTC-class product)"
            },
            {
              "goto": "s7",
              "id": "controlled",
              "label": "Controlled substance sample"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the sample a controlled substance?"
        },
        {
          "detail": "Enter every sample on the log before it goes into storage, regardless of how small the quantity.\n\nRecord: product name, lot number, expiration date, quantity received, representative name, date received",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Log the sample on receipt"
        },
        {
          "detail": "Store away from patient and public access, at the temperature the labeling specifies, and add the expiration date to the monthly expiration sweep so samples are not overlooked as \"not real inventory.\"\n\nWhy: Samples are handled casually because they arrived free, but they carry the same expiration and safety risk as purchased stock.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Store the samples in the designated area",
          "why": "Samples are handled casually because they arrived free, but they carry the same expiration and safety risk as purchased stock."
        },
        {
          "detail": "Dispense to a patient now, or hold in stock?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "hold",
              "label": "Hold in stock for a future patient"
            },
            {
              "goto": "s9",
              "id": "dispense",
              "label": "Dispense to today's patient"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Dispense to a patient now, or hold in stock?"
        },
        {
          "detail": "Sample logged and stored",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Sample logged and stored"
        },
        {
          "detail": "Controlled-substance samples must go through the practice's DEA-compliant controlled-substance receipt and storage process, not the general sample log — do not accept a controlled-substance sample outside that process.\n\nWhy: DEA recordkeeping requirements for controlled substances are stricter than a general sample log can satisfy.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Route to controlled-substance handling instead of this protocol",
          "why": "DEA recordkeeping requirements for controlled substances are stricter than a general sample log can satisfy."
        },
        {
          "detail": "Routed to controlled-substance process",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Routed to controlled-substance process"
        },
        {
          "detail": "Record the dispensing against the sample log so the office can trace which lot went to which patient if a recall is later issued.\n\nRecord: product, lot number, quantity dispensed, patient identifier, date, dispensing provider, any instructions given",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Log the dispensing event"
        },
        {
          "detail": "Sample logged and dispensing recorded",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Sample logged and dispensing recorded"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Manufacturer sample receipt, storage and dispensing log — A representative leaves product samples for patients.",
      "title": "Manufacturer sample receipt, storage and dispensing log",
      "trigger": "A representative leaves product samples for patients",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "label": "OSHA general PPE and hazard communication framework 29 CFR 1910.1200 applies to compressed gas SDS and labeling",
          "source": "OSHA general PPE and hazard communication framework 29 CFR 1910.1200 applies to compressed gas SDS and labeling",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "label": "For tank exchange and secure-storage practice — no vendor gas-supply contract referenced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for tank exchange and secure-storage practice — no vendor gas-supply contract referenced"
          },
          "source": "For tank exchange and secure-storage practice — no vendor gas-supply contract referenced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "inv-013",
      "kind": "operational",
      "materials": [
        "tank pressure gauge",
        "tank exchange log",
        "secured tank storage/chaining hardware",
        "spare/backup tank"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "As part of the routine facility check, read the pressure gauge on the active nitrous and oxygen tanks and compare to the low-pressure reorder threshold set by the practice.\n\nWhy: Running out mid-procedure interrupts patient care and, for oxygen, removes a component the emergency kit depends on.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Check nitrous and oxygen tank pressure gauges",
          "why": "Running out mid-procedure interrupts patient care and, for oxygen, removes a component the emergency kit depends on."
        },
        {
          "detail": "Tanks upright, chained or otherwise secured to prevent tip-over, valve caps on tanks not in use, stored away from heat sources and separated from incompatible gases. Performed on every check, not only on exchange days.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm secure storage of all tanks, active and backup"
        },
        {
          "detail": "Is either tank below the reorder threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "adequate",
              "label": "Both tanks above threshold"
            },
            {
              "goto": "s5",
              "id": "low",
              "label": "One or both tanks below threshold"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is either tank below the reorder threshold?"
        },
        {
          "detail": "Tank pressure adequate, no action needed",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Tank pressure adequate, no action needed"
        },
        {
          "detail": "Check whether a spare tank is already in storage that can be swapped in immediately, versus needing to wait for an exchange delivery.\n\nWhy: The practice should never be down to a single tank with no backup, since exchange delivery is not always same-day.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm a backup tank is on hand",
          "why": "The practice should never be down to a single tank with no backup, since exchange delivery is not always same-day."
        },
        {
          "detail": "Is a backup tank available?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "backup-available",
              "label": "Backup available — swap in and schedule routine exchange"
            },
            {
              "goto": "s10",
              "id": "no-backup",
              "label": "No backup available"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a backup tank available?"
        },
        {
          "detail": "Place the exchange order on the standard cycle and note the delivery date.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the routine tank exchange"
        },
        {
          "detail": "Update the tank exchange log so the pattern of usage over time is visible for future par-level planning.\n\nRecord: tank type, date ordered, date received, delivery/exchange vendor, pressure at time of order",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the exchange"
        },
        {
          "detail": "Tank exchange completed and logged",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Tank exchange completed and logged"
        },
        {
          "detail": "Order same-day or next-day exchange, and in the interim, adjust the day's schedule to avoid booking procedures requiring nitrous or relying on that oxygen supply if the margin is thin.\n\nWhy: Without a backup, the office must actively protect its emergency-oxygen capability, not just its convenience supply for sedation.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Place an expedited exchange order",
          "why": "Without a backup, the office must actively protect its emergency-oxygen capability, not just its convenience supply for sedation."
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Nitrous oxide and oxygen tank ordering, storage and exchange — A tank reads low or the exchange schedule comes due.",
      "title": "Nitrous oxide and oxygen tank ordering, storage and exchange",
      "trigger": "A tank reads low or the exchange schedule comes due",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA PPE standard 29 CFR 1910.132 and dental-specific bloodborne pathogens standard 29 CFR 1910.1030 require PPE be provided and available",
          "source": "OSHA PPE standard 29 CFR 1910.132 and dental-specific bloodborne pathogens standard 29 CFR 1910.1030 require PPE be provided and available",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.132"
        },
        {
          "kind": "public_domain",
          "label": "CDC Infection Prevention and Control Guidelines for Dental Settings — PPE selection and use",
          "source": "CDC Infection Prevention and Control Guidelines for Dental Settings — PPE selection and use",
          "url": "https://www.cdc.gov/oral-health/hcp/infection-prevention/index.html"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 15,
      "frequency": "monthly",
      "id": "inv-014",
      "kind": "operational",
      "materials": [
        "PPE par-level checklist (masks, gloves in all sizes, gowns, eyewear/face shields, bouffant caps)",
        "reorder form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Count masks (by level), gloves (by size, exam and sterile), isolation gowns, protective eyewear/face shields, and bouffant caps or head covers, against the par level set for each.\n\nWhy: PPE is used continuously through every clinical day, so a category running low is a near-term stoppage risk, not a slow-moving concern.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Count current stock of each PPE category",
          "why": "PPE is used continuously through every clinical day, so a category running low is a near-term stoppage risk, not a slow-moving concern."
        },
        {
          "detail": "Is any category below par?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "all-adequate",
              "label": "All categories at or above par"
            },
            {
              "goto": "s5",
              "id": "any-below",
              "label": "One or more categories below par"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is any category below par?"
        },
        {
          "detail": "Keep the monthly record on file for the exposure control plan documentation.\n\nRecord: date, counts per category, categories below par, reorder action taken",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the monthly PPE check result"
        },
        {
          "detail": "Monthly PPE stock check complete",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Monthly PPE stock check complete"
        },
        {
          "detail": "List the specific categories and quantities short, and route into the reorder-and-purchase-approval protocol as a compliance-priority item.\n\nWhy: PPE shortfalls are flagged as compliance-priority because operating without adequate PPE is an OSHA exposure-control violation, not just an operational inconvenience.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Flag the shortfall for reorder",
          "why": "PPE shortfalls are flagged as compliance-priority because operating without adequate PPE is an OSHA exposure-control violation, not just an operational inconvenience."
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "PPE stock check — Monthly stock check.",
      "title": "PPE stock check",
      "trigger": "Monthly stock check",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt) — cited as this class's general public floor for coverage purposes; not substantively about vendor pricing, which has no regulatory basis of its own",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt) — cited as this class's general public floor for coverage purposes; not substantively about vendor pricing, which has no regulatory basis of its own",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "generic",
          "label": "For a periodic vendor price comparison and consolidation review — no distributor named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a periodic vendor price comparison and consolidation review — no distributor named"
          },
          "source": "For a periodic vendor price comparison and consolidation review — no distributor named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 60,
      "frequency": "quarterly",
      "id": "inv-015",
      "kind": "operational",
      "materials": [
        "quarterly spend report by item",
        "distributor price comparison sheet",
        "vendor contract terms"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "List the top supply lines by dollar spend for the quarter, with vendor, unit price, and quantity.\n\nWhy: Comparing everything is wasteful busywork; the highest-spend items are where a price difference actually moves the budget.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the quarter's spend report by item and vendor",
          "why": "Comparing everything is wasteful busywork; the highest-spend items are where a price difference actually moves the budget."
        },
        {
          "detail": "For each high-spend item, check the price at the current distributor against at least one competing distributor, including any volume or loyalty terms already in place.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Compare current price against at least one alternative distributor for each top item"
        },
        {
          "detail": "Does switching or consolidating vendors clear the practice's savings threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-change",
              "label": "Current vendor arrangement remains most favorable"
            },
            {
              "goto": "s6",
              "id": "switch",
              "label": "A switch or consolidation clears the threshold"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does switching or consolidating vendors clear the practice's savings threshold?"
        },
        {
          "detail": "File the review for reference at the next quarter's comparison and for the supply-cost-variance review.\n\nRecord: items reviewed, price comparison results, decision (no change / switched), projected savings, approver",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the quarter's price review outcome"
        },
        {
          "detail": "Quarterly vendor price review complete",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Quarterly vendor price review complete"
        },
        {
          "detail": "Present the proposed switch with projected savings and any tradeoffs (delivery time, return policy, account history) for the owner's sign-off before changing the vendor relationship.\n\nWhy: A vendor switch affects more than price — delivery reliability and account terms are a business decision that belongs above the office manager's own authority.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner approves the vendor change.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner approves the vendor change",
          "why": "A vendor switch affects more than price — delivery reliability and account terms are a business decision that belongs above the office manager's own authority."
        },
        {
          "detail": "Update the reorder system's default vendor for the affected items and set a reminder to confirm the new pricing holds on the first order.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Execute the vendor switch or consolidation"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Quarterly vendor price review and consolidation — The quarter closes and the top supply lines are price-compared across distributors.",
      "title": "Quarterly vendor price review and consolidation",
      "trigger": "The quarter closes and the top supply lines are price-compared across distributors",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt) — cited as this class's general public floor for coverage purposes; not substantively about a supply-cost-to-collections KPI, which has no regulatory basis of its own — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt) — cited as this class's general public floor for coverage purposes; not substantively about a supply-cost-to-collections KPI, which has no regulatory basis of its own"
          },
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt) — cited as this class's general public floor for coverage purposes; not substantively about a supply-cost-to-collections KPI, which has no regulatory basis of its own — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "For a supply-cost-to-collections ratio review — common dental practice management benchmarking concept, no proprietary benchmark source cited as a specific percentage here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a supply-cost-to-collections ratio review — common dental practice management benchmarking concept, no proprietary benchmark source cited as a specific percentage here"
          },
          "source": "For a supply-cost-to-collections ratio review — common dental practice management benchmarking concept, no proprietary benchmark source cited as a specific percentage here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "inv-016",
      "kind": "operational",
      "materials": [
        "monthly collections report",
        "monthly supply spend report",
        "prior months' supply-cost-percentage trend"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Gather total collections for the month and total clinical/office supply spend for the same month from the accounting or PMS report.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the month's total collections and total supply spend"
        },
        {
          "detail": "Divide total supply spend by total collections for the month to get the percentage, and add it to the trend line against prior months.\n\nWhy: A single month's dollar figure means little on its own; the trend against collections is what shows whether costs are drifting relative to production.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Calculate supply cost as a percentage of collections",
          "why": "A single month's dollar figure means little on its own; the trend against collections is what shows whether costs are drifting relative to production."
        },
        {
          "detail": "Is the ratio within the practice's target band?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "within-band",
              "label": "Within target band"
            },
            {
              "goto": "s6",
              "id": "outside-band",
              "label": "Outside target band"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is the ratio within the practice's target band?"
        },
        {
          "detail": "Add the figure to the running trend file used at the next numbers meeting.\n\nRecord: month, total collections, total supply spend, percentage, target band, action assigned if any",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the month's ratio and any action taken"
        },
        {
          "detail": "Monthly supply cost variance review complete",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Monthly supply cost variance review complete"
        },
        {
          "detail": "Break down the month's spend by category (clinical materials, PPE, lab, office) to identify whether the variance is a one-time event (a large restock month, a price increase, a new procedure type) or a sustained trend.\n\nWhy: The same ratio spike can mean a one-time bulk order or a genuine cost creep — the response differs entirely depending on which it is.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Investigate the drivers of the variance",
          "why": "The same ratio spike can mean a one-time bulk order or a genuine cost creep — the response differs entirely depending on which it is."
        },
        {
          "detail": "Does the variance require a corrective action?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "one-time",
              "label": "One-time event, no action needed"
            },
            {
              "goto": "s8",
              "id": "sustained",
              "label": "Sustained trend requiring action"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the variance require a corrective action?"
        },
        {
          "detail": "Direct the office manager to run an out-of-cycle vendor price review, tighten par levels, or review a specific high-cost category identified in the investigation, with a target date to reassess.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Assign a corrective action to the office manager"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Supply cost as a percentage of collections review — Monthly with the numbers meeting.",
      "title": "Supply cost as a percentage of collections review",
      "trigger": "Monthly with the numbers meeting",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200 (SDS on receipt)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "regulation",
          "label": "FDA recalls 21 CFR Part 7; Medical Device Reporting 21 CFR Part 803; voluntary MedWatch Form 3500; dental devices 21 CFR Part 872",
          "source": "FDA recalls 21 CFR Part 7; Medical Device Reporting 21 CFR Part 803; voluntary MedWatch Form 3500; dental devices 21 CFR Part 872",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule — minimum necessary and third-party presence in treatment areas requires patient authorization for anyone who is not part of the treatment team",
          "source": "HIPAA Privacy Rule — minimum necessary and third-party presence in treatment areas requires patient authorization for anyone who is not part of the treatment team",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — anyone present in a clinical area during a procedure with exposure potential is covered by exposure-control expectations",
          "source": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 — anyone present in a clinical area during a procedure with exposure potential is covered by exposure-control expectations",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "facility",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "inv-017",
      "kind": "operational",
      "materials": [
        "visitor sign-in log",
        "rep credential/ID check",
        "written patient consent form for a third-party observer",
        "confidentiality acknowledgment form",
        "PPE for the visitor",
        "office visitor badge"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Front desk or office manager greets the representative, confirms the company they represent and the purpose of the visit (dropping off samples, checking stock, or asking to be present chairside for a specific procedure such as an implant or CAD/CAM case).\n\nWhy: The office needs to know intent before granting any access — a stock-check visit and a chairside-observation request have very different consent and safety requirements.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Sales representative requests to observe or support a case, or arrives unannounced",
          "why": "The office needs to know intent before granting any access — a stock-check visit and a chairside-observation request have very different consent and safety requirements."
        },
        {
          "detail": "Confirm company-issued ID or business card, log name, company, date, time and stated purpose in the visitor sign-in log, and issue a visitor badge if the office uses one.\n\nRecord: Visitor sign-in log entry: rep name, company, date/time, stated purpose.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify representative identity and log the visit"
        },
        {
          "detail": "Is the representative requesting to be present in the operatory during a patient procedure?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "stock-only",
              "label": "No — supply drop-off, stock check, or a hallway conversation only"
            },
            {
              "advised": false,
              "goto": "s6",
              "id": "chairside",
              "label": "Yes — the rep wants to observe or provide technical support during a procedure"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the representative requesting to be present in the operatory during a patient procedure?"
        },
        {
          "detail": "Escort the rep to the supply or business area only; the rep does not enter clinical treatment areas and has no patient contact. Any product samples or new items follow the standard receiving and SDS-filing protocols.\n\nWhy: A stock-only visit carries no PHI exposure and does not need patient consent or a licensed sign-off.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Handle as a routine supply visit",
          "why": "A stock-only visit carries no PHI exposure and does not need patient consent or a licensed sign-off."
        },
        {
          "detail": "Routine supply visit complete",
          "id": "s5",
          "kind": "step",
          "title": "Routine supply visit complete"
        },
        {
          "detail": "The treating dentist reviews the specific case (e.g. implant placement, CAD/CAM restoration) and decides whether outside technical support from the rep is appropriate, and confirms the rep is not directing clinical decisions or touching the patient.\n\nWhy: The dentist remains the sole clinical decision-maker; a representative may provide technical/product information but never performs or directs a clinical act — this is a licensed-signoff gate, not a courtesy.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist decides whether the representative's chairside presence is clinically appropriate for this case.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist decides whether the representative's chairside presence is clinically appropriate for this case",
          "why": "The dentist remains the sole clinical decision-maker; a representative may provide technical/product information but never performs or directs a clinical act — this is a licensed-signoff gate, not a courtesy."
        },
        {
          "detail": "Dentist's decision on the request",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "decline",
              "label": "Decline — reschedule the rep for a non-clinical visit or a training session outside patient hours"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "approve",
              "label": "Approve, contingent on patient consent and PPE compliance"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Dentist's decision on the request"
        },
        {
          "detail": "Office manager informs the rep the request is declined for this patient/procedure and offers an alternative time such as a lunch-and-learn or after-hours product demonstration.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Communicate the decision to the representative"
        },
        {
          "detail": "Request declined; alternative offered",
          "id": "s9",
          "kind": "step",
          "title": "Request declined; alternative offered"
        },
        {
          "detail": "Front desk or assistant explains to the patient, in plain language and before the visit, that a company representative would like to be present during the procedure to provide technical support, names the company, and asks whether the patient consents. The patient may decline without affecting their care. Consent is documented on a signed form filed in the chart.\n\nWhy: HIPAA treats a non-treatment-team observer as a third party requiring patient authorization; consent must be free, informed, and obtained before the visit — never assumed or bundled into a general intake form.\n\nRecord: Signed patient consent form naming the observing representative and company, filed in the chart.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain the patient's written, informed consent before the representative enters the operatory.",
            "type": "safety"
          },
          "id": "s10",
          "kind": "gate",
          "role": "front-desk",
          "title": "Obtain the patient's written, informed consent before the representative enters the operatory",
          "why": "HIPAA treats a non-treatment-team observer as a third party requiring patient authorization; consent must be free, informed, and obtained before the visit — never assumed or bundled into a general intake form."
        },
        {
          "detail": "Did the patient consent?",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "declines",
              "label": "Patient declines observer presence"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "consents",
              "label": "Patient consents in writing"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the patient consent?"
        },
        {
          "detail": "The representative does not enter the operatory for this patient; the procedure proceeds without the rep present. The patient's decision is not discussed with the rep beyond 'not for this visit.'\n\nWhy: Patient autonomy over who is present during their care is absolute regardless of the clinical or business value of the rep's presence.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Honor the patient's decision",
          "why": "Patient autonomy over who is present during their care is absolute regardless of the clinical or business value of the rep's presence."
        },
        {
          "detail": "Observer presence declined by patient; procedure proceeds without rep",
          "id": "s13",
          "kind": "step",
          "title": "Observer presence declined by patient; procedure proceeds without rep"
        },
        {
          "detail": "Representative signs a confidentiality acknowledgment (no photos, no discussion of the patient outside the office, no access to the chart beyond what the dentist shows for product context), dons required PPE (mask, eyewear, gown as the office requires), and is briefed on where to stand and what not to touch.\n\nWhy: A generic functional equivalent of a standard visitor/vendor confidentiality and infection-control briefing — every clinical area treats an outside visitor the same as staff for exposure-control purposes.\n\nRecord: Signed confidentiality acknowledgment filed with the visit log.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Confidentiality acknowledgment and PPE fit before entering the operatory",
          "why": "A generic functional equivalent of a standard visitor/vendor confidentiality and infection-control briefing — every clinical area treats an outside visitor the same as staff for exposure-control purposes."
        },
        {
          "detail": "The rep may answer product questions, hand the dentist product literature, or advise on device setup, but does not place hands on the patient, does not make clinical recommendations to the patient, and does not appear in any patient-facing photo or video without separate consent.\n\nWhy: Keeps the line between 'technical product support to the clinician' and 'clinical care,' which stays solely with licensed staff.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Representative observes/supports without touching the patient or directing care",
          "why": "Keeps the line between 'technical product support to the clinician' and 'clinical care,' which stays solely with licensed staff."
        },
        {
          "detail": "Escort the rep out of the operatory once the clinical portion is finished; the rep does not linger near other patients' charts or operatories.",
          "id": "s16",
          "kind": "step",
          "role": "assistant",
          "title": "Procedure completes; representative exits the clinical area"
        },
        {
          "detail": "File the signed patient consent form and the confidentiality acknowledgment in the appropriate records (patient chart and vendor-visit file respectively); note the visit outcome in the visitor sign-in log.\n\nRecord: Visitor log closed out with outcome; consent form in patient chart; confidentiality acknowledgment in vendor file.",
          "id": "s17",
          "kind": "step",
          "role": "office-manager",
          "title": "Close out the visit record"
        },
        {
          "detail": "Compliance officer periodically reviews a sample of logged rep visits to confirm consent forms were obtained and filed before each chairside visit, and flags any gaps for retraining.\n\nWhy: A spot-check closes the loop on a process that otherwise relies entirely on front-line staff remembering to gate access every time.",
          "id": "s18",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Periodic compliance review of rep-visit consent practices",
          "why": "A spot-check closes the loop on a process that otherwise relies entirely on front-line staff remembering to gate access every time."
        },
        {
          "detail": "Representative visit protocol complete",
          "id": "s19",
          "kind": "step",
          "title": "Representative visit protocol complete"
        }
      ],
      "subclass": "inventory-ordering-and-product-safety",
      "summary": "Sales representative visit and rep presence in the operatory during a procedure — A rep asks to observe or support an implant or CAD/CAM case chairside, or drops in during patient hours.",
      "title": "Sales representative visit and rep presence in the operatory during a procedure",
      "trigger": "A rep asks to observe or support an implant or CAD/CAM case chairside, or drops in during patient hours",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "ipc-001",
      "kind": "compliance",
      "materials": [
        "current written infection control program document",
        "CDC guideline summary",
        "posting board or shared drive location",
        "revision log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "dentist",
        "sterilization-tech",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Compliance officer retrieves the current written infection control program and checks the CDC dental infection-control summary page and the state dental board's minimum standards page for any updates since the last review.\n\nWhy: The program has to reflect the CURRENT public floor, not the version that was current at last year's review.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull current program and this year's guidance updates",
          "why": "The program has to reflect the CURRENT public floor, not the version that was current at last year's review."
        },
        {
          "detail": "Confirm the written program still covers: standard precautions/PPE, hand hygiene, instrument reprocessing (Spaulding classification), sterilization monitoring, dental unit waterlines, surface disinfection, sharps safety and exposure control, and the CA 16 CCR §1005 minimum-standards list.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compare program against the required-category checklist"
        },
        {
          "detail": "Does the program need updates?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-change",
              "label": "No changes needed — program is current"
            },
            {
              "goto": "s8",
              "id": "changes",
              "label": "Changes needed to match current guidance or new equipment/procedure"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the program need updates?"
        },
        {
          "detail": "Post or link the current program where all clinical staff can access it (break room binder or shared drive) and distribute a summary of what changed, if anything.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Post and distribute the current program"
        },
        {
          "detail": "Front-line and clinical staff each confirm they have reviewed the current program; office manager tracks who has not yet acknowledged.",
          "id": "s5",
          "kind": "step",
          "role": "all-staff",
          "title": "All staff acknowledge the current program"
        },
        {
          "detail": "Record the review date, reviewer, dentist sign-off date, and a one-line summary of any changes in the compliance file.\n\nRecord: compliance file: annual review log entry (date, reviewer, changes, sign-off)",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the annual review"
        },
        {
          "detail": "Annual review complete",
          "id": "s7",
          "kind": "step",
          "title": "Annual review complete"
        },
        {
          "detail": "Compliance officer drafts redlined updates to the affected sections of the written program, noting the source of each change (guideline citation or regulation section).",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the updated sections"
        },
        {
          "detail": "The dentist of record reviews and signs off on the drafted updates before they take effect, since the program sets binding clinical infection-control practice for the office.\n\nWhy: The written program controls clinical behavior; a compliance-only edit without clinician sign-off risks a change the clinical team was never asked to validate.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the updated program before it governs clinical work.",
            "role": "dentist of record",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the updated program before it governs clinical work",
          "why": "The written program controls clinical behavior; a compliance-only edit without clinician sign-off risks a change the clinical team was never asked to validate."
        },
        {
          "detail": "Incorporate the signed-off changes, stamp the document with a new revision date, and replace the prior version in the shared location.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Finalize and date the revised program"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Written infection control program annual review and posting — The annual review date arrives, CDC or state minimum standards change, or a new sterilizer or procedure is introduced.",
      "title": "Written infection control program annual review and posting",
      "trigger": "The annual review date arrives, CDC or state minimum standards change, or a new sterilizer or procedure is introduced",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "ipc-002",
      "kind": "compliance",
      "materials": [
        "written infection control program",
        "designation memo template",
        "personnel file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Practice owner identifies a staff member (often a sterilization technician or senior clinical assistant) with working knowledge of the office's reprocessing and infection-control workflow.\n\nWhy: Every dental practice's written program requires one named, accountable individual — the role does not run itself by default.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Identify a candidate familiar with sterilization and clinical workflow",
          "why": "Every dental practice's written program requires one named, accountable individual — the role does not run itself by default."
        },
        {
          "detail": "Is the candidate a current employee or a new hire?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "existing",
              "label": "Current employee taking on the role"
            },
            {
              "goto": "s3",
              "id": "new-hire",
              "label": "New hire brought on specifically for this role"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is the candidate a current employee or a new hire?"
        },
        {
          "detail": "Write out the coordinator's duties and the authority they hold (e.g., can pull a waterline out of service, can halt a sterilization cycle) and add it to the written program.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the role description and scope of authority"
        },
        {
          "detail": "Confirm the role covers: waterline testing schedule, sterilizer/biological-indicator monitoring, staff health and immunization record oversight, monthly audit walkthroughs, and new-hire infection-control orientation.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Core coordinator duties"
        },
        {
          "detail": "Practice owner signs a short designation memo naming the coordinator, the effective date, and the scope of authority; the memo is attached to the written program.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner formally signs the designation.",
            "role": "practice owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner formally signs the designation"
        },
        {
          "detail": "File the signed designation memo in the written program appendix and in the coordinator's personnel file.\n\nRecord: written program appendix + personnel file: signed coordinator designation memo",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the designation"
        },
        {
          "detail": "Give the new coordinator access to the waterline test kit, sterilization logs, audit checklists, and training materials, and introduce them to staff as the named contact for infection-control questions.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hand the coordinator their access and materials"
        },
        {
          "detail": "Coordinator designated and onboarded",
          "id": "s8",
          "kind": "step",
          "title": "Coordinator designated and onboarded"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Designating and onboarding the infection control coordinator — The practice opens, the current coordinator leaves, or the written program lacks a named coordinator.",
      "title": "Designating and onboarding the infection control coordinator",
      "trigger": "The practice opens, the current coordinator leaves, or the written program lacks a named coordinator",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — dental unit waterline quality (≤500 CFU/mL potable-water standard)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — dental unit waterline quality (≤500 CFU/mL potable-water standard)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 40,
      "frequency": "quarterly",
      "id": "ipc-003",
      "kind": "compliance",
      "materials": [
        "waterline test kit (in-office dip-slide or send-out lab kit)",
        "EPA-registered waterline treatment/shock product per manufacturer instructions",
        "DUWL log",
        "unit-out-of-service signage"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "assistant",
        "compliance-officer",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Sterilization technician checks the DUWL log against the testing calendar and lists every operatory unit due this quarter, plus any new or freshly serviced unit awaiting first test.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Pull the testing schedule and confirm due units"
        },
        {
          "detail": "For each due unit, collect a water sample from the handpiece line(s), the air/water syringe, and the ultrasonic scaler line, labeling each sample with unit ID, line, and date.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Gather samples from every line on each unit"
        },
        {
          "detail": "Run the in-office dip-slide test or package the samples for the send-out lab kit, following the manufacturer's instructions exactly for sample handling and incubation temperature.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Process the samples per the test kit's instructions"
        },
        {
          "detail": "Allow the incubation period specified by the test kit manufacturer (in-office dip-slides typically 48–72 hours) or the lab's stated turnaround before reading results.\n\nWhy: Reading a dip-slide early undercounts colony growth and can mask an out-of-range line.",
          "id": "s4",
          "kind": "timer",
          "role": "sterilization-tech",
          "timer_seconds": 259200,
          "title": "Wait for incubation/lab turnaround",
          "why": "Reading a dip-slide early undercounts colony growth and can mask an out-of-range line."
        },
        {
          "detail": "Result versus the 500 CFU/mL threshold",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "in-range",
              "label": "At or below 500 CFU/mL — within the CDC potable-water standard"
            },
            {
              "goto": "s8",
              "id": "out-of-range",
              "label": "Above 500 CFU/mL"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Result versus the 500 CFU/mL threshold"
        },
        {
          "detail": "Record the unit ID, line, test date, product/kit used, and CFU/mL result in the DUWL log.\n\nRecord: DUWL log: unit, line, date, product, CFU/mL result",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the passing result"
        },
        {
          "detail": "Quarterly testing cycle closed for this unit",
          "id": "s7",
          "kind": "step",
          "title": "Quarterly testing cycle closed for this unit"
        },
        {
          "detail": "Compliance officer and dentist review the out-of-range result and decide whether the affected unit is taken out of service for non-emergency procedures until remediated, per the written infection control program. If a genuinely emergent procedure must still be performed on that unit before remediation, use an independent sterile-water delivery system (a self-contained bottled sterile-water reservoir) rather than the affected line.\n\nWhy: A waterline above the CDC threshold is a patient-safety exposure risk on every subsequent procedure until it is brought back into range.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance/dentist decide the unit's service status.",
            "role": "compliance officer + dentist of record",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Compliance/dentist decide the unit's service status",
          "why": "A waterline above the CDC threshold is a patient-safety exposure risk on every subsequent procedure until it is brought back into range."
        },
        {
          "detail": "Apply the EPA-registered waterline shock/treatment product to the affected lines exactly per the manufacturer's instructions for concentration and dwell time.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Perform shock treatment"
        },
        {
          "detail": "Flush every line on the unit per the manufacturer's post-shock flush instructions before returning to the retest step.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Flush all lines"
        },
        {
          "detail": "Hold the unit out of clinical use for the dwell/wait period specified on the treatment product label before retesting.",
          "id": "s11",
          "kind": "timer",
          "role": "sterilization-tech",
          "timer_seconds": 86400,
          "title": "Wait the manufacturer's post-treatment dwell period"
        },
        {
          "detail": "Retest result",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "retest-pass",
              "label": "Retest at or below 500 CFU/mL"
            },
            {
              "goto": "s9",
              "id": "retest-fail",
              "label": "Retest still above 500 CFU/mL"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Retest result"
        },
        {
          "detail": "Remove out-of-service signage, notify clinical staff the unit has passed retest, and resume normal use.",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Return the unit to service"
        },
        {
          "detail": "Record the out-of-range date, product/dwell used, retest date, and pass result in the DUWL log and the compliance file.\n\nRecord: DUWL log + compliance file: remediation timeline and retest result",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the remediation outcome"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Dental unit waterline quarterly testing, shock treatment and out-of-range remediation — The quarterly test date, a result above 500 CFU/mL, a new or serviced unit placed in service, or a patient infection suspected to be linked to unit water.",
      "title": "Dental unit waterline quarterly testing, shock treatment and out-of-range remediation",
      "trigger": "The quarterly test date, a result above 500 CFU/mL, a new or serviced unit placed in service, or a patient infection suspected to be linked to unit water",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC/ACIP Immunization of Health-Care Personnel",
          "source": "CDC/ACIP Immunization of Health-Care Personnel",
          "url": "https://www.cdc.gov/vaccines/hcp/imz-guidelines/index.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 (employer-provided Hepatitis B vaccination and declination requirement)",
          "source": "OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030 (employer-provided Hepatitis B vaccination and declination requirement)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "ipc-004",
      "kind": "compliance",
      "materials": [
        "ACIP healthcare-personnel vaccine recommendation list",
        "TB screening test (TST or IGRA)",
        "vaccination declination form",
        "confidential employee health file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "compliance-officer",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "HR checks the CDC/ACIP recommended vaccine list for healthcare personnel (Hepatitis B, MMR, Varicella, Tdap, seasonal influenza, and any currently recommended respiratory-illness vaccine) for the new clinical hire.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Pull the current ACIP healthcare-personnel vaccine list"
        },
        {
          "detail": "Request vaccination records or immunity titers for each recommended vaccine, plus baseline TB screening (TST or IGRA) documentation.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Request documentation from the employee"
        },
        {
          "detail": "Does the employee have complete documentation?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "complete",
              "label": "Complete records/titers provided"
            },
            {
              "goto": "s9",
              "id": "missing",
              "label": "Records missing, incomplete, or employee declines a vaccine"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hr",
          "title": "Does the employee have complete documentation?"
        },
        {
          "detail": "If baseline TB screening is not on file, schedule a TST or IGRA before the employee begins unsupervised clinical duties.",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Schedule baseline TB screening if not documented"
        },
        {
          "detail": "File all records, titers, and any declination form in the confidential employee health file, kept separate from the general personnel file.\n\nRecord: confidential employee health file: immunization/titer/TB records, declinations",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "File in the confidential employee health file"
        },
        {
          "detail": "HR gives the compliance officer an aggregate count of complete vs. pending records for the program audit, without sharing individual health details.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Send a summary count (no names) to the compliance officer"
        },
        {
          "detail": "At the annual reconciliation date, confirm every current clinical staff member's file is complete and log the reconciliation date.\n\nRecord: compliance file: annual reconciliation log entry",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual reconciliation entry"
        },
        {
          "detail": "Staff health records current",
          "id": "s8",
          "kind": "step",
          "title": "Staff health records current"
        },
        {
          "detail": "Per the OSHA bloodborne pathogens standard, offer the Hepatitis B vaccination series (and other ACIP-recommended vaccines per office policy) at no cost to the employee.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Offer the vaccination series at no cost to the employee"
        },
        {
          "detail": "If the employee declines after being offered the vaccine, HR has them sign a declination form acknowledging the offer and the risk, witnessed by HR.\n\nWhy: OSHA's bloodborne pathogens standard specifically requires a signed declination on file when an employee refuses the Hepatitis B vaccine after it was offered.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Signed declination if the employee still declines.",
            "type": "safety"
          },
          "id": "s10",
          "kind": "gate",
          "role": "hr",
          "title": "Signed declination if the employee still declines",
          "why": "OSHA's bloodborne pathogens standard specifically requires a signed declination on file when an employee refuses the Hepatitis B vaccine after it was offered."
        },
        {
          "detail": "File the declination and note that the employee may request the vaccination series at any later date at no cost.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Note the employee remains eligible to accept later"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Staff immunization, titer and TB screening records — A clinical hire starts, an exposure occurs, or the annual records reconciliation is due.",
      "title": "Staff immunization, titer and TB screening records",
      "trigger": "A clinical hire starts, an exposure occurs, or the annual records reconciliation is due",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — hand hygiene",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — hand hygiene",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "ipc-005",
      "kind": "compliance",
      "materials": [
        "hand hygiene observation checklist (moment-based)",
        "aggregate tally sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "hygienist",
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Compliance officer schedules a monthly observation window without telling staff the exact time in advance, to capture normal behavior rather than performance for an audience.\n\nWhy: Announced audits inflate the observed compliance rate and hide the real baseline.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule an unannounced observation session",
          "why": "Announced audits inflate the observed compliance rate and hide the real baseline."
        },
        {
          "detail": "Track hand hygiene at: before patient contact, before an aseptic task, after a body-fluid exposure risk, after patient contact, and after touching patient surroundings.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Use the hand-hygiene moment-based observation checklist"
        },
        {
          "detail": "Observe a mix of hygienists, assistants, and the dentist across several patient encounters, without singling out one individual.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Observe randomly selected staff during patient care"
        },
        {
          "detail": "Record aggregate compliant/non-compliant counts per staff role (not per patient identity) for each of the 5 moments observed.\n\nRecord: hand hygiene audit tally: aggregate compliant/non-compliant counts by role and moment",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Tally compliant vs. non-compliant moments"
        },
        {
          "detail": "Does the compliance rate meet the practice's internal threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "meets",
              "label": "Meets or exceeds the internal threshold"
            },
            {
              "goto": "s9",
              "id": "below",
              "label": "Below the internal threshold"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the compliance rate meet the practice's internal threshold?"
        },
        {
          "detail": "Present the aggregate compliance rate at the next team huddle with positive reinforcement for the observed strong moments.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Share aggregate results at a team huddle"
        },
        {
          "detail": "Record the audit date, aggregate compliance rate, and any coaching or training actions taken.\n\nRecord: compliance file: monthly hand hygiene audit log",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the audit outcome"
        },
        {
          "detail": "Monthly hand hygiene audit closed",
          "id": "s8",
          "kind": "step",
          "title": "Monthly hand hygiene audit closed"
        },
        {
          "detail": "Compliance officer has a private coaching conversation with any staff member observed repeatedly missing key moments, and schedules a hand hygiene refresher.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Individual coaching and refresher training"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Hand hygiene observation audit and feedback — The monthly audit date, or an infection-control complaint from a patient.",
      "title": "Hand hygiene observation audit and feedback",
      "trigger": "The monthly audit date, or an infection-control complaint from a patient",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "monthly",
      "id": "ipc-006",
      "kind": "compliance",
      "materials": [
        "monthly audit walkthrough checklist",
        "corrective-action tracker"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "assistant",
        "sterilization-tech",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Compliance officer, joined by the sterilization technician and office manager, begins the scheduled monthly walkthrough of every operatory and the instrument-processing area.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Start the monthly walkthrough"
        },
        {
          "detail": "Confirm: barriers changed and dated, surface disinfectant within its expiration/open-date window, sharps containers below the manufacturer's marked fill line (commonly around three-quarters full), DUWL log current for each unit, PPE stock adequate, and instrument processing follows a one-way dirty-to-clean flow with signage.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check every required item"
        },
        {
          "detail": "Physically inspect every operatory and the sterilization/processing area item by item, not from memory or a prior month's notes.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Walk each operatory and the processing area against the checklist"
        },
        {
          "detail": "Record each deficiency with its location, description, and the staff member responsible for that area.\n\nRecord: monthly audit walkthrough log: deficiencies by location",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Note any deficiencies found"
        },
        {
          "detail": "Were any deficiencies found?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "none",
              "label": "No deficiencies found"
            },
            {
              "goto": "s8",
              "id": "found",
              "label": "One or more deficiencies found"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Were any deficiencies found?"
        },
        {
          "detail": "Confirm each assigned corrective action is closed (or still open with a new due date), and file the completed walkthrough in the monthly audit file.\n\nRecord: compliance file: monthly audit walkthrough, closure status",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm closure and log the audit"
        },
        {
          "detail": "Monthly walkthrough closed",
          "id": "s7",
          "kind": "step",
          "title": "Monthly walkthrough closed"
        },
        {
          "detail": "For each deficiency, assign an owner and a due date in the corrective-action tracker.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign corrective action"
        },
        {
          "detail": "Allow the assigned window before the follow-up check — typically 7 days for a routine item.",
          "id": "s9",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 604800,
          "title": "Re-check window before follow-up"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Monthly operatory and instrument-processing-area infection-control audit walkthrough — Monthly — barriers, disinfectant dating, sharps fill, waterline log, PPE stock, processing workflow and documentation checked; also before a board inspection.",
      "title": "Monthly operatory and instrument-processing-area infection-control audit walkthrough",
      "trigger": "Monthly — barriers, disinfectant dating, sharps fill, waterline log, PPE stock, processing workflow and documentation checked; also before a board inspection",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilization monitoring (biological indicator/spore testing at least weekly, and with every load containing an implantable device, for each sterilizer in use)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilization monitoring (biological indicator/spore testing at least weekly, and with every load containing an implantable device, for each sterilizer in use)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "public_domain",
          "label": "FDA reprocessing of reusable medical devices guidance",
          "source": "FDA reprocessing of reusable medical devices guidance",
          "url": "https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices"
        },
        {
          "kind": "generic",
          "label": "Generic state dental board / OSHA employee-record retention practice — no single public-floor source states a specific sterilization-log retention period; retention windows commonly cited range 2-5 years by state board, so the practice's own state board requirement governs and this line needs licensed/operator confirmation — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic state dental board / OSHA employee-record retention practice — no single public-floor source states a specific sterilization-log retention period; retention windows commonly cited range 2-5 years by state board, so the practice's own state board requirement governs and this line needs licensed/operator confirmation"
          },
          "source": "Generic state dental board / OSHA employee-record retention practice — no single public-floor source states a specific sterilization-log retention period; retention windows commonly cited range 2-5 years by state board, so the practice's own state board requirement governs and this line needs licensed/operator confirmation — Practice policy — no published authority governs this step."
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "ipc-007",
      "kind": "compliance",
      "materials": [
        "sterilization cycle log",
        "biological indicator (spore test) results",
        "records retention file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Sterilization technician gathers every autoclave cycle log entry for the month across all sterilizers in use.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Pull the month's sterilization logs"
        },
        {
          "detail": "Check every cycle log entry has date, cycle number, temperature, pressure, time, and operator initials, and that biological indicator (spore test) results are present at least weekly for each sterilizer in use, and with every load containing an implantable device.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Confirm log completeness"
        },
        {
          "detail": "Any failed spore test or gap in the log?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean",
              "label": "No failures and no gaps"
            },
            {
              "goto": "s6",
              "id": "issue",
              "label": "A failed spore test or a logging gap found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Any failed spore test or gap in the log?"
        },
        {
          "detail": "File the completed monthly logs (and any failure investigation record) in the retention file for the period set by the current state dental board record-retention requirement — confirm the exact figure with a licensed reviewer rather than assuming a fixed number, since no cited public-floor source sets one directly.\n\nRecord: records retention file: monthly sterilization logs, retained per current state board requirement (licensed-review flagged)",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the monthly logs and retain per the current state board requirement"
        },
        {
          "detail": "Monthly sterilization log review closed",
          "id": "s5",
          "kind": "step",
          "title": "Monthly sterilization log review closed"
        },
        {
          "detail": "Compliance officer reviews the failed spore test result and identifies which loads that sterilizer processed since its last passing test, to determine whether reprocessing is needed before those instruments are used again.\n\nWhy: A failed biological indicator means sterility of every load since the last pass is unconfirmed — the office needs a documented decision, not an assumption, before those instruments touch a patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review of the failure before instruments are used.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review of the failure before instruments are used",
          "why": "A failed biological indicator means sterility of every load since the last pass is unconfirmed — the office needs a documented decision, not an assumption, before those instruments touch a patient."
        },
        {
          "detail": "Pull any instrument sets processed since the last passing spore test, quarantine them, and reprocess per the sterilizer manufacturer's instructions before returning them to circulation.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Quarantine and reprocess affected instruments"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Sterilization and monitoring log monthly review and retention — Month-end, or a records request from the state board or a patient.",
      "title": "Sterilization and monitoring log monthly review and retention",
      "trigger": "Month-end, or a records request from the state board or a patient",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "ipc-008",
      "kind": "compliance",
      "materials": [
        "written infection control program",
        "orientation checklist",
        "PPE for demonstration",
        "acknowledgment sign-off form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "sterilization-tech",
        "hygienist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Compliance officer schedules the infection control orientation session to happen before the new hire's first unsupervised clinical shift.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule orientation before the first clinical shift"
        },
        {
          "detail": "Walk through: standard precautions and PPE selection/use, hand hygiene, instrument reprocessing (Spaulding classification), sterilization monitoring, dental unit waterline protocol, surface disinfection, sharps safety, and the exposure/needlestick protocol.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Cover the core orientation topics"
        },
        {
          "detail": "Sterilization technician walks the new hire through the actual instrument-processing area, showing the dirty-to-clean one-way workflow in practice.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Walk through the processing area with the sterilization technician"
        },
        {
          "detail": "New hire demonstrates correct donning and doffing of PPE and correct hand hygiene technique under observation.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hands-on PPE and hand hygiene demonstration"
        },
        {
          "detail": "New hire reviews the full written infection control program and signs an acknowledgment confirming they have read and understood it, per the CA 16 CCR §1005 addendum requirement.\n\nWhy: California's minimum standards specifically require documented review and sign-off of the written program by clinical staff, not just verbal orientation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Written program review and signed acknowledgment (CA addendum).",
            "role": "compliance officer, signed by the new hire",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Written program review and signed acknowledgment (CA addendum)",
          "why": "California's minimum standards specifically require documented review and sign-off of the written program by clinical staff, not just verbal orientation."
        },
        {
          "detail": "File the signed program-review acknowledgment in the new hire's personnel file.\n\nRecord: personnel file: signed written-program acknowledgment",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the signed acknowledgment"
        },
        {
          "detail": "New hire shadows a sterilization technician or senior hygienist for at least one full shift before working unsupervised.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Shadow shift before working unsupervised"
        },
        {
          "detail": "Log the orientation date, topics covered, and trainer name in the new hire's onboarding record.\n\nRecord: onboarding record: orientation date, topics, trainer",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log orientation completion"
        },
        {
          "detail": "New hire oriented and cleared for unsupervised clinical work",
          "id": "s9",
          "kind": "step",
          "title": "New hire oriented and cleared for unsupervised clinical work"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Infection control orientation for new clinical staff (CA addendum: written program review and sign-off) — A new hygienist, assistant or sterilization technician starts.",
      "title": "Infection control orientation for new clinical staff (CA addendum: written program review and sign-off)",
      "trigger": "A new hygienist, assistant or sterilization technician starts",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        },
        {
          "kind": "public_domain",
          "label": "CDC/ACIP Immunization of Health-Care Personnel",
          "source": "CDC/ACIP Immunization of Health-Care Personnel",
          "url": "https://www.cdc.gov/vaccines/hcp/imz-guidelines/index.html"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "ipc-009",
      "kind": "compliance",
      "materials": [
        "license renewal roster with expiration dates",
        "infection-control CE course certificates",
        "state board CE requirement summary",
        "tracking spreadsheet or CE tracking tool"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "hygienist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "List every dentist, hygienist and assistant holding a license or registration that carries an infection-control CE requirement, with each person's renewal date.\n\nWhy: A missed renewal because no one was tracking the date puts a clinician's license, and the practice's ability to treat, at risk.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the roster of licensees and their upcoming renewal dates",
          "why": "A missed renewal because no one was tracking the date puts a clinician's license, and the practice's ability to treat, at risk."
        },
        {
          "detail": "Is any licensee's renewal window within 90 days?\n\nWhy: Ninety days gives enough runway to complete a course before the deadline without a rush filing.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "within-window",
              "label": "Yes, at least one renewal is within 90 days"
            },
            {
              "goto": "s8",
              "id": "not-yet",
              "label": "No renewals due within 90 days"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is any licensee's renewal window within 90 days?",
          "why": "Ninety days gives enough runway to complete a course before the deadline without a rush filing."
        },
        {
          "detail": "Check the licensee's completed course certificates against the state board's infection-control CE hour minimum for that license type and renewal cycle; note the gap in hours, if any.\n\nWhy: The infection-control CE requirement is a distinct line item within the broader CE total, and boards audit it separately.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify infection-control CE hours completed against the state requirement",
          "why": "The infection-control CE requirement is a distinct line item within the broader CE total, and boards audit it separately."
        },
        {
          "detail": "Does the licensee meet the infection-control CE minimum?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "met",
              "label": "Requirement met, certificates on file"
            },
            {
              "goto": "s10",
              "id": "short",
              "label": "Licensee is short of the required hours"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the licensee meet the infection-control CE minimum?"
        },
        {
          "detail": "Have the office manager confirm the certificate count and hours match the board's posted infection-control CE minimum before the file is closed out as complete.\n\nWhy: A missed hour discovered after renewal risks the licensee's ability to practice, so a second set of eyes checks the math before the file is closed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor confirms the licensee is clear to renew.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor confirms the licensee is clear to renew",
          "why": "A missed hour discovered after renewal risks the licensee's ability to practice, so a second set of eyes checks the math before the file is closed."
        },
        {
          "detail": "File the certificate of completion in the licensee's personnel file and update the tracking roster with the completed hours and next renewal date.\n\nRecord: Certificate of completion filed in the licensee's personnel file; tracking roster updated with the completed hours and next renewal date.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "File the CE certificate and update the tracking roster"
        },
        {
          "detail": "Renewal tracked and certificate on file",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Renewal tracked and certificate on file"
        },
        {
          "detail": "Note the date of the next renewal window on the tracking calendar and close this run.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Set the next roster check"
        },
        {
          "detail": "No renewal action needed this cycle",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "No renewal action needed this cycle"
        },
        {
          "detail": "Tell the affected dentist, hygienist or assistant how many infection-control CE hours are still needed and the date by which a qualifying course must be completed to renew on time.\n\nWhy: The licensee, not the office manager, is the one who must enroll in and complete the course.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the licensee of the CE gap and the deadline",
          "why": "The licensee, not the office manager, is the one who must enroll in and complete the course."
        },
        {
          "detail": "Follow up before the deadline to confirm the licensee finished a state-board-accepted infection-control CE course and obtained a certificate.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the licensee has completed a qualifying course"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Tracking the infection-control continuing-education requirement for licensees (CA addendum) — A dentist, hygienist or assistant license renewal window opens.",
      "title": "Tracking the infection-control continuing-education requirement for licensees (CA addendum)",
      "trigger": "A dentist, hygienist or assistant license renewal window opens",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California consumer complaint process — infection control is a listed complaint/investigation category the board can act on",
          "source": "Dental Board of California consumer complaint process — infection control is a listed complaint/investigation category the board can act on",
          "url": "https://www.dbc.ca.gov/consumers/index.shtml"
        },
        {
          "kind": "regulation",
          "label": "California Code of Regulations Title 17 §2500 — health care providers, including dentists, must report a case or suspected case of a notifiable disease/condition to the local health officer",
          "source": "California Code of Regulations Title 17 §2500 — health care providers, including dentists, must report a case or suspected case of a notifiable disease/condition to the local health officer",
          "url": "https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/ReportableDiseases.pdf"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "ipc-010",
      "kind": "compliance",
      "materials": [
        "complaint intake form",
        "sterilization log for the date in question",
        "operatory assignment schedule",
        "patient of record list for potential notification",
        "incident report template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Record what the patient saw or believes happened, the date and approximate time of the visit, the operatory if known, and the treating clinician, without arguing or explaining in the moment.\n\nWhy: An accurate first account, not a defensive one, is what the investigation is built on.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Take the complaint in the patient's own words",
          "why": "An accurate first account, not a defensive one, is what the investigation is built on."
        },
        {
          "detail": "Explain that the practice will review sterilization records and staff for the visit in question, and confirm the patient is comfortable with that.\n\nWhy: The complaint touches the patient's own visit record, so the patient's consent to that use is sought before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the patient consents to their account being used in an internal investigation.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm the patient consents to their account being used in an internal investigation",
          "why": "The complaint touches the patient's own visit record, so the patient's consent to that use is sought before proceeding."
        },
        {
          "detail": "Give the compliance officer the intake notes, the visit date, and the treating clinician's name so the formal investigation can begin.\n\nWhy: A complaint about instrument reprocessing or reuse is a patient-safety matter that needs a named owner, not an informal chat.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the complaint to the compliance officer",
          "why": "A complaint about instrument reprocessing or reuse is a patient-safety matter that needs a named owner, not an informal chat."
        },
        {
          "detail": "Retrieve the sterilization cycle log, biological indicator results, operatory turnover checklist, and staff assignment for the visit date and operatory named.\n\nWhy: Documented cycle records are the objective evidence for or against the complaint, independent of anyone's memory.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the sterilization log and operatory records for the date in question",
          "why": "Documented cycle records are the objective evidence for or against the complaint, independent of anyone's memory."
        },
        {
          "detail": "Do the records support a confirmed infection-control lapse?\n\nWhy: The records, not the complaint alone, determine whether corrective action and notification are warranted.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "confirmed",
              "label": "Records show a gap or a failed sterilization cycle for that date"
            },
            {
              "goto": "s13",
              "id": "unsubstantiated",
              "label": "Records are complete and cycles passed for that date"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Do the records support a confirmed infection-control lapse?",
          "why": "The records, not the complaint alone, determine whether corrective action and notification are warranted."
        },
        {
          "detail": "Have the treating or supervising dentist review the confirmed lapse, the exposure risk it created, and the scope of any patient notification needed before anything is communicated externally.\n\nWhy: Whether an infection-control lapse creates a clinical exposure risk requiring notification is a licensed clinical judgment, not an administrative one.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed clinician review before notification or corrective action.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed clinician review before notification or corrective action",
          "why": "Whether an infection-control lapse creates a clinical exposure risk requiring notification is a licensed clinical judgment, not an administrative one."
        },
        {
          "detail": "Send the notification the dentist approved, including what happened, what is being done about it, and who to contact with questions.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the complaining patient, and any other affected patients, per the dentist's determination"
        },
        {
          "detail": "Does the confirmed lapse meet the board- or health-department-reporting threshold?\n\nWhy: A confirmed lapse with actual or suspected patient infection can trigger a duty to report — to the state dental board's complaint/investigation process, or to the local health officer under the state notifiable-condition reporting rule — and that decision belongs in the workflow as a checked step, not left to informal judgment.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "reportable",
              "label": "Meets the practice's board-reporting or health-department notifiable-condition threshold"
            },
            {
              "goto": "s10",
              "id": "not-reportable",
              "label": "Does not meet either reporting threshold"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the confirmed lapse meet the board- or health-department-reporting threshold?",
          "why": "A confirmed lapse with actual or suspected patient infection can trigger a duty to report — to the state dental board's complaint/investigation process, or to the local health officer under the state notifiable-condition reporting rule — and that decision belongs in the workflow as a checked step, not left to informal judgment."
        },
        {
          "detail": "Submit the report to the state dental board's complaint/investigation intake and, if the confirmed condition is a notifiable disease, to the local health officer, per the practice's board-reporting trigger criteria; keep the submission confirmation for the incident file.\n\nWhy: Once the threshold is met, the report has to actually reach the board or the local health officer before the incident can be considered closed.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the required external report",
          "why": "Once the threshold is met, the report has to actually reach the board or the local health officer before the incident can be considered closed."
        },
        {
          "detail": "Fix the specific process gap the investigation found (retraining, an added log check, an equipment repair) and set a date to confirm it holds.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Put a corrective action in place"
        },
        {
          "detail": "Write up the complaint, the findings, the clinician sign-off where applicable, and the corrective action or notification taken, and file it in the compliance incident file.\n\nRecord: Complaint, findings, clinician sign-off if applicable, corrective action and notification sent, filed in the compliance incident file.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the investigation and outcome"
        },
        {
          "detail": "Complaint investigated and closed",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Complaint investigated and closed"
        },
        {
          "detail": "Explain what was reviewed and that the records for that date and operatory show no lapse, and invite the patient to raise any further concern.",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Respond to the patient with the findings"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Investigating a patient complaint about infection-control practices — A patient reports seeing unwrapped instruments or a reused item, or contracts an infection after treatment.",
      "title": "Investigating a patient complaint about infection-control practices",
      "trigger": "A patient reports seeing unwrapped instruments or a reused item, or contracts an infection after treatment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA reprocessing of reusable medical devices guidance",
          "source": "FDA reprocessing of reusable medical devices guidance",
          "url": "https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "ipc-011",
      "kind": "compliance",
      "materials": [
        "manufacturer instructions for use (IFU) document",
        "sterilizer validated cycle list",
        "device reprocessing log binder"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Find the IFU document that shipped with the device, or download it from the manufacturer's published instructions if it did not arrive in the box.\n\nWhy: The IFU is the manufacturer's validated reprocessing method for that specific device and is the standard the practice's cycle must match.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Locate the manufacturer's instructions for use for the device",
          "why": "The IFU is the manufacturer's validated reprocessing method for that specific device and is the standard the practice's cycle must match."
        },
        {
          "detail": "Was a usable IFU located?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "found",
              "label": "IFU located and readable"
            },
            {
              "goto": "s7",
              "id": "not-found",
              "label": "No IFU located"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Was a usable IFU located?"
        },
        {
          "detail": "Check the IFU's specified cycle type, temperature, pressure and exposure time (or the disinfectant contact time for a semi-critical item) against the sterilizer cycles the practice already runs and has biologically validated.\n\nWhy: A device requiring a cycle the practice's sterilizer cannot run, or has not validated, is not ready for use no matter how new or clean it looks.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Compare the IFU's required cycle to the practice's validated sterilizer cycles",
          "why": "A device requiring a cycle the practice's sterilizer cannot run, or has not validated, is not ready for use no matter how new or clean it looks."
        },
        {
          "detail": "Does an existing validated cycle satisfy the IFU?\n\nWhy: This determines whether the device can go into rotation as-is or the reprocessing workflow itself needs to change first.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "matches",
              "label": "An existing validated cycle satisfies the IFU"
            },
            {
              "goto": "s8",
              "id": "mismatch",
              "label": "No existing cycle satisfies the IFU"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Does an existing validated cycle satisfy the IFU?",
          "why": "This determines whether the device can go into rotation as-is or the reprocessing workflow itself needs to change first."
        },
        {
          "detail": "Write the device name, IFU source, assigned sterilizer cycle and verification date into the device reprocessing log binder before the device enters rotation.\n\nRecord: Device name, IFU source, assigned sterilizer cycle, and the date verification was completed, filed in the device reprocessing log.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the device and its assigned cycle in the reprocessing binder"
        },
        {
          "detail": "Device verified and cleared for use",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Device verified and cleared for use"
        },
        {
          "detail": "Request the reprocessing instructions in writing before the device is used on a patient.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Contact the manufacturer or vendor for the IFU"
        },
        {
          "detail": "Give the compliance officer the IFU and the specific gap so a new validated cycle, alternate equipment, or a decision to return the device can be made before it is used.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Escalate the cycle mismatch to the compliance officer"
        },
        {
          "detail": "Tag the device as not-in-service and store it separately from ready-to-use instrumentation.\n\nWhy: A device the sterilizer cannot properly reprocess must not reach a patient by accident during the gap.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hold the device out of clinical use until resolved",
          "why": "A device the sterilizer cannot properly reprocess must not reach a patient by accident during the gap."
        },
        {
          "detail": "Device held pending cycle resolution",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Device held pending cycle resolution"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Verifying reprocessing instructions for a newly purchased reusable device — A new handpiece, scaler tip or instrument kit arrives before first use.",
      "title": "Verifying reprocessing instructions for a newly purchased reusable device",
      "trigger": "A new handpiece, scaler tip or instrument kit arrives before first use",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC/ACIP Immunization of Health-Care Personnel",
          "source": "CDC/ACIP Immunization of Health-Care Personnel",
          "url": "https://www.cdc.gov/vaccines/hcp/imz-guidelines/index.html"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "ipc-012",
      "kind": "compliance",
      "materials": [
        "staff immunization records",
        "current local/state respiratory illness activity level",
        "masking and screening posture policy",
        "vaccination offer sign-up sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Review the current published local or state respiratory illness activity level (influenza, RSV, COVID-19) to set this season's posture.\n\nWhy: Masking and screening posture is calibrated to actual community activity, not a fixed calendar date alone.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check current local respiratory illness activity level",
          "why": "Masking and screening posture is calibrated to actual community activity, not a fixed calendar date alone."
        },
        {
          "detail": "Circulate the sign-up sheet for on-site or referred seasonal vaccination (influenza and any other CDC/ACIP-recommended seasonal vaccine for health-care personnel) and record who accepts or declines.\n\nWhy: Staff vaccination against seasonal respiratory illness reduces the chance of a clinician transmitting to patients or being out sick during peak season.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Offer seasonal vaccination to clinical staff",
          "why": "Staff vaccination against seasonal respiratory illness reduces the chance of a clinician transmitting to patients or being out sick during peak season."
        },
        {
          "detail": "Write down each staff member's name, the vaccine offered, and whether they accepted or declined, and file it in the staff immunization record.\n\nRecord: Staff member name, vaccine offered, and accepted/declined status, filed in the staff immunization record.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record vaccination offer and acceptance status"
        },
        {
          "detail": "Is local respiratory illness activity elevated?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "elevated",
              "label": "Activity is elevated"
            },
            {
              "goto": "s9",
              "id": "baseline",
              "label": "Activity is at baseline"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is local respiratory illness activity elevated?"
        },
        {
          "detail": "Extend masking beyond aerosol-generating procedures to all patient-facing encounters and add a symptom screening question at check-in, per the practice's posture policy.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Raise masking and screening posture"
        },
        {
          "detail": "Tell the whole team the current masking and screening posture and where to find the vaccination sign-up sheet.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief all staff on this season's posture"
        },
        {
          "detail": "Wait until the next scheduled check (every two weeks during peak season) to re-check local activity and adjust posture if needed.\n\nWhy: Respiratory illness activity can shift within a season, so the posture is revisited rather than set once and forgotten.",
          "id": "s7",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 1209600,
          "title": "Set the next posture review point",
          "why": "Respiratory illness activity can shift within a season, so the posture is revisited rather than set once and forgotten."
        },
        {
          "detail": "Seasonal readiness posture set for this cycle",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Seasonal readiness posture set for this cycle"
        },
        {
          "detail": "Continue standard precautions (masking for aerosol-generating procedures, routine hand hygiene) without the elevated-activity additions.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Keep standard masking and screening posture"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Seasonal respiratory-illness readiness: staff vaccination offer, screening and masking posture — Respiratory season begins (autumn), or local respiratory illness activity rises.",
      "title": "Seasonal respiratory-illness readiness: staff vaccination offer, screening and masking posture",
      "trigger": "Respiratory season begins (autumn), or local respiratory illness activity rises",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        },
        {
          "kind": "public_domain",
          "label": "CDC return-to-work guidance for health-care personnel with an acute viral respiratory infection (24 hours fever-free without fever-reducing medication and symptoms improving, as one return-to-work benchmark among the practice's exclusion criteria)",
          "source": "CDC return-to-work guidance for health-care personnel with an acute viral respiratory infection (24 hours fever-free without fever-reducing medication and symptoms improving, as one return-to-work benchmark among the practice's exclusion criteria)",
          "url": "https://www.cdc.gov/respiratory-viruses/hcp/index.html"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "ipc-013",
      "kind": "compliance",
      "materials": [
        "exclusion and return-to-work policy",
        "same-day schedule for reassignment",
        "return-to-work clearance form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer",
        "dentist",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask the team member what symptoms they have, when they started, and whether they involve fever, active skin or eye lesions, or a diagnosed contagious condition (e.g., active herpetic whitlow, conjunctivitis, influenza).\n\nWhy: A quick symptom screen at the door prevents an actively contagious team member from starting a clinical shift.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Screen the team member's symptoms on arrival",
          "why": "A quick symptom screen at the door prevents an actively contagious team member from starting a clinical shift."
        },
        {
          "detail": "Do the symptoms meet the practice's work-exclusion criteria?\n\nWhy: Fever, active herpetic lesions, and conjunctivitis are recognized transmission risks in a clinical setting and are treated as exclusion triggers rather than judgment calls in the moment.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "exclude",
              "label": "Meets exclusion criteria"
            },
            {
              "goto": "s10",
              "id": "no-exclusion",
              "label": "Does not meet exclusion criteria"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Do the symptoms meet the practice's work-exclusion criteria?",
          "why": "Fever, active herpetic lesions, and conjunctivitis are recognized transmission risks in a clinical setting and are treated as exclusion triggers rather than judgment calls in the moment."
        },
        {
          "detail": "Have a supervising dentist confirm the exclusion call and any patient-contact restriction, since the risk being managed is direct clinical transmission to patients.\n\nWhy: Whether the specific presentation poses a transmission risk to patients is a clinical judgment call, not an administrative one.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed clinician confirms exclusion is warranted.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed clinician confirms exclusion is warranted",
          "why": "Whether the specific presentation poses a transmission risk to patients is a clinical judgment call, not an administrative one."
        },
        {
          "detail": "Tell the team member they are excluded from patient contact, and state the specific clinical criteria that must be met before returning — for a febrile respiratory illness, 24 hours fever-free without fever-reducing medication and symptoms improving per current CDC guidance; for a skin/eye lesion or other diagnosed condition, the criteria set by the reviewing dentist or the treating physician's clearance.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Send the team member home and note the expected return criteria"
        },
        {
          "detail": "Give the office manager the excluded team member's scheduled patients so coverage can be arranged or patients rescheduled.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hand the day's schedule to the office manager for coverage or rescheduling"
        },
        {
          "detail": "Hold the exclusion until the team member reports meeting the stated clinical criteria for return.\n\nWhy: A fixed minimum wait, checked against the actual criteria rather than the calendar alone, avoids an early return that is still contagious.",
          "id": "s6",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 86400,
          "title": "Wait for the team member to meet return-to-work criteria",
          "why": "A fixed minimum wait, checked against the actual criteria rather than the calendar alone, avoids an early return that is still contagious."
        },
        {
          "detail": "Has the team member met the stated return-to-work criteria?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "met",
              "label": "Criteria met"
            },
            {
              "goto": "s6",
              "id": "not-met",
              "label": "Criteria not yet met"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Has the team member met the stated return-to-work criteria?"
        },
        {
          "detail": "Write down the exclusion date, the criteria met, and the clearance to return to patient contact, and file it in the team member's personnel/health file.\n\nRecord: Exclusion date, criteria met, and clearance to return to patient contact, filed in the team member's personnel/health file.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Document return-to-work clearance"
        },
        {
          "detail": "Team member returned to patient contact",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Team member returned to patient contact"
        },
        {
          "detail": "Document that the symptoms did not meet exclusion criteria and the team member is working as scheduled.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Clear the team member for the shift"
        },
        {
          "detail": "Write down the date, the symptoms reported, and the decision to clear the team member for the shift, and file it in the daily screening log.\n\nRecord: Date, symptoms reported, and the decision to clear for the shift, filed in the daily screening log.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the screening decision"
        },
        {
          "detail": "Team member cleared for the shift, no exclusion",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Team member cleared for the shift, no exclusion"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Ill or contagious team member: work exclusion and return-to-work criteria — A team member arrives with fever, active herpetic whitlow, conjunctivitis or a diagnosed contagious illness.",
      "title": "Ill or contagious team member: work exclusion and return-to-work criteria",
      "trigger": "A team member arrives with fever, active herpetic whitlow, conjunctivitis or a diagnosed contagious illness",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        },
        {
          "kind": "public_domain",
          "label": "CDC 1991 recommendations for preventing transmission of HIV and HBV to patients during exposure-prone invasive procedures (MMWR RR-8), updated by the 2012 CDC recommendations for the management of HBV-infected health-care providers and students (MMWR RR-3) — establishes the expert-review-panel mechanism for assessing an infected clinician's exposure-prone procedures",
          "source": "CDC 1991 recommendations for preventing transmission of HIV and HBV to patients during exposure-prone invasive procedures (MMWR RR-8), updated by the 2012 CDC recommendations for the management of HBV-infected health-care providers and students (MMWR RR-3) — establishes the expert-review-panel mechanism for assessing an infected clinician's exposure-prone procedures",
          "url": "https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6103a1.htm"
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "ipc-014",
      "kind": "compliance",
      "materials": [
        "confidential HR file for the disclosing clinician",
        "state board guidance on bloodborne-pathogen-infected health-care workers",
        "expert-panel referral contact",
        "practice restriction documentation template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "dentist",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Take the disclosure or post-exposure test result from the clinician or the testing source in a private setting, and limit who is told to the minimum needed to act.\n\nWhy: This is sensitive personal health information about a staff member, and confidentiality protects both the individual and the integrity of the process.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Receive the disclosure or positive test result confidentially",
          "why": "This is sensitive personal health information about a staff member, and confidentiality protects both the individual and the integrity of the process."
        },
        {
          "detail": "Inform the practice owner and compliance officer that a bloodborne-pathogen disclosure has occurred and that an expert-panel referral is being started, without spreading detail beyond what each needs to act.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Bring the practice owner and compliance officer in on a need-to-know basis"
        },
        {
          "detail": "Connect the clinician with an expert panel or occupational health resource qualified to assess exposure-prone procedures and recommend practice restrictions, per state board guidance.\n\nWhy: Whether and how a bloodborne-pathogen-infected clinician can safely continue exposure-prone procedures is a specialized clinical determination outside the practice's own competence to make alone.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Refer the clinician to an expert review panel",
          "why": "Whether and how a bloodborne-pathogen-infected clinician can safely continue exposure-prone procedures is a specialized clinical determination outside the practice's own competence to make alone."
        },
        {
          "detail": "Hold any change to the clinician's duties until the expert panel's written determination and recommended restrictions, if any, are received.\n\nWhy: Acting before the panel's determination risks either an unsafe continuation of duties or an unnecessary restriction not supported by the actual risk assessment.",
          "id": "s4",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 604800,
          "title": "Wait for the expert panel's determination",
          "why": "Acting before the panel's determination risks either an unsafe continuation of duties or an unnecessary restriction not supported by the actual risk assessment."
        },
        {
          "detail": "Have the supervising or owner dentist review the expert panel's determination and confirm how the recommended restrictions, if any, will be implemented in the practice's scheduling and procedure assignments.\n\nWhy: Translating an expert panel's clinical recommendation into day-to-day practice restrictions is a licensed clinical decision with direct patient-safety consequences.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed review of the panel's determination before implementing restrictions.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed review of the panel's determination before implementing restrictions",
          "why": "Translating an expert panel's clinical recommendation into day-to-day practice restrictions is a licensed clinical decision with direct patient-safety consequences."
        },
        {
          "detail": "Adjust the clinician's procedure assignments and schedule to match the panel's determination, communicating only what staff involved in scheduling need to know to carry it out.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Implement any restrictions in scheduling and procedure assignment"
        },
        {
          "detail": "Write down the disclosure date, the expert-panel referral, the determination received, and the restrictions implemented, and file it in a confidential HR file kept separate from the general personnel file.\n\nRecord: Disclosure date, expert-panel referral, determination received, restrictions implemented and review date, filed in a confidential HR file separate from the general personnel file.",
          "id": "s7",
          "kind": "step",
          "role": "hr",
          "title": "Document the process in a confidential file"
        },
        {
          "detail": "Schedule the next check-in to confirm the restriction, or its lifting, is still appropriate per any updated panel guidance.",
          "id": "s8",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 7776000,
          "title": "Set the periodic monitoring review"
        },
        {
          "detail": "Restriction implemented and under periodic review",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Restriction implemented and under periodic review"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Team member with a bloodborne infection: expert-panel review and practice restrictions — A clinician discloses HBV, HCV or HIV infection, or post-exposure testing returns positive.",
      "title": "Team member with a bloodborne infection: expert-panel review and practice restrictions",
      "trigger": "A clinician discloses HBV, HCV or HIV infection, or post-exposure testing returns positive",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "Generic office animal-program practice guidance (no dental-specific public floor found; standard health-care-setting animal visitation controls applied by analogy) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic office animal-program practice guidance (no dental-specific public floor found; standard health-care-setting animal visitation controls applied by analogy)"
          },
          "source": "Generic office animal-program practice guidance (no dental-specific public floor found; standard health-care-setting animal visitation controls applied by analogy) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "infection-prevention-program",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "once",
      "id": "ipc-015",
      "kind": "compliance",
      "materials": [
        "animal vaccination and grooming records",
        "clinical-area access policy",
        "patient allergy/comfort signage",
        "patient opt-out sign-up log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Decide and write down which areas (reception, private offices) the animal is allowed in, and which clinical areas (operatories, sterilization/instrument-processing area) are off-limits at all times.\n\nWhy: Keeping the animal out of clinical and instrument-processing areas is the core control that separates a comfort-animal program from an infection-control risk.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Define which areas of the office the animal may access",
          "why": "Keeping the animal out of clinical and instrument-processing areas is the core control that separates a comfort-animal program from an infection-control risk."
        },
        {
          "detail": "Confirm current vaccination records and a recent grooming/hygiene check for the animal, and set a reminder for the next renewal.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Verify the animal's vaccination and grooming records"
        },
        {
          "detail": "Post visible signage at the entrance noting the animal is on site, and add a question to new-patient intake asking whether the patient has an allergy or preference to avoid the animal.\n\nWhy: Patients with an animal allergy or a fear of dogs need advance notice, not a surprise encounter in the waiting room.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Post signage and add an allergy/opt-out flag to intake",
          "why": "Patients with an animal allergy or a fear of dogs need advance notice, not a surprise encounter in the waiting room."
        },
        {
          "detail": "Does the patient's record carry an allergy or opt-out flag for the animal?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "flagged",
              "label": "Patient has a flag on file"
            },
            {
              "goto": "s7",
              "id": "no-flag",
              "label": "No flag on file"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient's record carry an allergy or opt-out flag for the animal?"
        },
        {
          "detail": "Crate or relocate the animal away from reception and the patient's path for the duration of that patient's visit.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Keep the animal away from the flagged patient's visit"
        },
        {
          "detail": "Visit accommodated per patient's flag",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Visit accommodated per patient's flag"
        },
        {
          "detail": "No accommodation needed for this visit; the animal remains in its permitted areas per the access policy.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Continue normal program operation"
        },
        {
          "detail": "Hold until the next annual review of the access policy, health records and any incidents logged during the year.",
          "id": "s8",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 31536000,
          "title": "Wait for the annual program review"
        },
        {
          "detail": "Program reviewed and continuing",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Program reviewed and continuing"
        }
      ],
      "subclass": "infection-prevention-program-administration",
      "summary": "Office comfort animal or therapy-dog program: allergy, infection-control and consent rules — The practice wants to keep a comfort dog on site or host a therapy-animal visit.",
      "title": "Office comfort animal or therapy-dog program: allergy, infection-control and consent rules",
      "trigger": "The practice wants to keep a comfort dog on site or host a therapy-animal visit",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-34 Rev.1 Contingency Planning Guide for Federal Information Systems - public domain",
          "source": "NIST SP 800-34 Rev.1 Contingency Planning Guide for Federal Information Systems - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/34/r1/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 20,
      "frequency": "daily",
      "id": "itd-001",
      "kind": "operational",
      "materials": [
        "backup job dashboard or log",
        "backup verification checklist",
        "isolated test-restore environment or sandbox"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Open the backup software's job log and confirm last night's job shows Completed with no error flags, for every system backed up (practice management data, imaging, email/document store).\n\nWhy: A silent backup failure is invisible until the day it is needed; a daily two-minute check is the cheapest insurance in the whole protocol.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check the backup job dashboard each morning",
          "why": "A silent backup failure is invisible until the day it is needed; a daily two-minute check is the cheapest insurance in the whole protocol."
        },
        {
          "detail": "Did every job report success?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "All jobs completed successfully"
            },
            {
              "goto": "s6",
              "id": "no",
              "label": "One or more jobs failed or did not run"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Did every job report success?"
        },
        {
          "detail": "Initial and date the backup log or checklist confirming today's jobs succeeded; note total backup size and any warnings even if the job itself completed.\n\nRecord: Daily backup verification checklist entry (date, initials, job status, size, warnings)",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the daily check"
        },
        {
          "detail": "Is this the monthly restore-test date?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no",
              "label": "Not this month's test date"
            },
            {
              "goto": "s8",
              "id": "yes",
              "label": "Monthly restore test is due"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Is this the monthly restore-test date?"
        },
        {
          "detail": "Backup verification cycle complete",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Backup verification cycle complete"
        },
        {
          "detail": "Notify the office manager the same day a backup job fails or does not run; do not wait for the next scheduled check. The IT vendor investigates the cause (storage full, credential expired, job disabled) same-day and re-runs the job.\n\nWhy: Two consecutive missed backups without escalation is how practices discover, only during a real loss, that they have no recovery point.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate a failed or missing backup job.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Escalate a failed or missing backup job",
          "why": "Two consecutive missed backups without escalation is how practices discover, only during a real loss, that they have no recovery point."
        },
        {
          "detail": "Resolve the underlying cause (free storage, renew credential, re-enable the job) and manually trigger a re-run before end of day; confirm success before closing the ticket.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Fix the cause and re-run the backup"
        },
        {
          "detail": "Pick one representative record (or a small non-production dataset) and restore it into an isolated, access-limited sandbox that is not connected to the live network - never restore a test into the production system.\n\nWhy: A backup that has never been restored is a hope, not a plan; the isolated environment keeps a test restore from itself becoming a PHI exposure.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Restore a sample chart to an isolated test environment",
          "why": "A backup that has never been restored is a hope, not a plan; the isolated environment keeps a test restore from itself becoming a PHI exposure."
        },
        {
          "detail": "Confirm: (1) the file opens without corruption, (2) the record content matches what is expected, (3) the restore completed within the practice's target restore time objective, (4) the sandbox is torn down or wiped after verification.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Verify the restored data"
        },
        {
          "detail": "Record pass/fail, restore time achieved, and any corrective action needed, in the contingency plan test log.\n\nRecord: Monthly restore-test log (date, sample tested, result, restore time, corrective action)",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the monthly restore test result"
        },
        {
          "detail": "Is this the annual full restore drill date?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no",
              "label": "Not the annual drill date"
            },
            {
              "goto": "s12",
              "id": "yes",
              "label": "Annual full-system restore drill is due"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this the annual full restore drill date?"
        },
        {
          "detail": "Simulate a total loss: restore the full practice management system and imaging store into an isolated environment, time the full recovery, and confirm the practice could resume operations within the documented recovery time objective.\n\nWhy: An annual full drill is the only way to know the contingency plan actually works end to end, not just for one file.",
          "id": "s12",
          "kind": "step",
          "role": "it-vendor",
          "title": "Run the annual full-system restore drill",
          "why": "An annual full drill is the only way to know the contingency plan actually works end to end, not just for one file."
        },
        {
          "detail": "Deliver a written summary of the drill (recovery time achieved vs target, gaps found, remediation plan) to the practice owner and compliance officer for the contingency-plan file.",
          "id": "s13",
          "kind": "step",
          "role": "it-vendor",
          "title": "Report drill results to the practice owner and compliance officer"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Daily backup completion check, monthly test restore and annual restore drill — Daily — job status confirmed; monthly a sample chart is restored; the nightly job reports failure.",
      "title": "Daily backup completion check, monthly test restore and annual restore drill",
      "trigger": "Daily — job status confirmed; monthly a sample chart is restored; the nightly job reports failure",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "CISA / HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "source": "CISA / HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "url": "https://405d.hhs.gov/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 45,
      "frequency": "weekly",
      "id": "itd-002",
      "kind": "operational",
      "materials": [
        "patch management tool or vendor update portal",
        "maintenance window schedule",
        "pre-patch backup confirmation"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Verify the most recent backup completed successfully (per itd-001) before applying any patch that touches the practice management system, imaging software, or server OS.\n\nWhy: A patch is the single most common cause of a preventable outage; a fresh backup turns a bad patch into a rollback instead of a crisis.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Confirm a current backup exists before patching",
          "why": "A patch is the single most common cause of a preventable outage; a fresh backup turns a bad patch into a rollback instead of a crisis."
        },
        {
          "detail": "List pending updates across categories: operating system security patches, practice management software updates, imaging/sensor software and firmware, network device firmware, and endpoint security/antivirus definitions.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Review available updates"
        },
        {
          "detail": "Does any update carry a critical security severity rating?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "critical",
              "label": "Yes - critical or actively-exploited vulnerability"
            },
            {
              "goto": "s5",
              "id": "routine",
              "label": "No - routine/non-critical updates only"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Does any update carry a critical security severity rating?"
        },
        {
          "detail": "Apply a critical security patch as soon as practical rather than waiting for the weekly window, scheduling around patient hours where possible.\n\nWhy: An actively exploited vulnerability left open for a week is an unacceptable window for a system holding patient records.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Apply the critical patch outside the normal window if needed",
          "why": "An actively exploited vulnerability left open for a week is an unacceptable window for a system holding patient records."
        },
        {
          "detail": "Apply OS, application, imaging and firmware updates during the scheduled off-hours window; stagger reboots so at least one workstation remains available if urgently needed.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Apply routine updates during the maintenance window"
        },
        {
          "detail": "Confirm each patched system boots normally, the practice management software opens and logs in correctly, imaging capture and printing work, and no error is logged in the first 15 minutes after patching.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Post-patch verification"
        },
        {
          "detail": "Did any system fail post-patch verification?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "pass",
              "label": "All systems verified working"
            },
            {
              "goto": "s10",
              "id": "fail",
              "label": "A system failed verification"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Did any system fail post-patch verification?"
        },
        {
          "detail": "Record which systems were patched, which updates were applied, any rollback, and the verification result.\n\nRecord: Weekly patch log (date, systems, updates applied, verification result, rollbacks)",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the patch cycle"
        },
        {
          "detail": "Weekly patch cycle complete",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Weekly patch cycle complete"
        },
        {
          "detail": "Uninstall or roll back the specific update that caused the failure, restore from the pre-patch backup if the system will not roll back cleanly, and document the failure before re-attempting on a future cycle.",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Roll back the failed patch"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Weekly patch and update cycle (OS, practice software, imaging, firmware) — The weekly maintenance window.",
      "title": "Weekly patch and update cycle (OS, practice software, imaging, firmware)",
      "trigger": "The weekly maintenance window",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "itd-003",
      "kind": "operational",
      "materials": [
        "role-based access template",
        "new hire onboarding form",
        "system access request ticket"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the person's exact job title, start date, and which systems their role requires (practice management, imaging, email, scheduling, billing/clearinghouse) using the role-based access template for that position.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the new hire's or changed role"
        },
        {
          "detail": "Complete the system access request ticket naming the specific systems and permission level (view-only, standard, or administrative) the role template calls for.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the access request to IT"
        },
        {
          "detail": "Any request for administrative access, or access beyond what the role template specifies, requires the office manager's (or practice owner's) explicit sign-off before IT provisions it.\n\nWhy: Access creep - granting broader permissions than a role needs because it is easier than asking twice - is the single most common least-privilege failure; a named approver closes that gap.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner or office manager approves any access beyond the standard template.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "office-manager",
          "title": "Owner or office manager approves any access beyond the standard template",
          "why": "Access creep - granting broader permissions than a role needs because it is easier than asking twice - is the single most common least-privilege failure; a named approver closes that gap."
        },
        {
          "detail": "Provision only the systems and permission level named in the approved request; do not copy permissions from a similar existing employee, since that can silently carry forward excess access.\n\nWhy: Copying another account's permissions is the fastest way for least-privilege to erode over time.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Create the account at the minimum permission level for the role",
          "why": "Copying another account's permissions is the fastest way for least-privilege to erode over time."
        },
        {
          "detail": "Require multi-factor authentication on first login and issue a temporary password that must be changed at first use.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Enroll the account in MFA and set a temporary password"
        },
        {
          "detail": "Deliver login credentials to the office manager (not to the new hire directly by unsecured channel) for in-person or secure handoff on the start date.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand credentials to the office manager for delivery"
        },
        {
          "detail": "Confirm the new hire successfully logs in, sets a new password, and completes MFA enrollment on day one.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm first login and add to the access roster"
        },
        {
          "detail": "Add the account to the master access roster: name, role, systems granted, permission level, date provisioned, approver.\n\nRecord: Access roster entry (name, role, systems, permission level, date, approver)",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the provisioning"
        },
        {
          "detail": "Provisioning complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Provisioning complete"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "User account provisioning with least privilege — A new hire starts or a role changes.",
      "title": "User account provisioning with least privilege",
      "trigger": "A new hire starts or a role changes",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "itd-004",
      "kind": "operational",
      "materials": [
        "master access roster",
        "deprovisioning checklist",
        "key/badge inventory"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "office-manager",
        "hr",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "As soon as a resignation, termination, or end-of-contract date is confirmed - including an unannounced same-day termination - HR notifies the office manager and IT vendor immediately, not at end of day.\n\nWhy: A revoked account that waits until 'end of day' on a contested termination is a same-day breach window, which is exactly the scenario this protocol exists to close.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "HR notifies IT and the office manager of the separation the moment it is known",
          "why": "A revoked account that waits until 'end of day' on a contested termination is a same-day breach window, which is exactly the scenario this protocol exists to close."
        },
        {
          "detail": "Is this an involuntary or for-cause separation?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "forcause",
              "label": "Involuntary / for-cause / immediate"
            },
            {
              "goto": "s9",
              "id": "planned",
              "label": "Planned, amicable resignation with notice period"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this an involuntary or for-cause separation?"
        },
        {
          "detail": "Disable the account (do not delete - preserve for audit) across every system on the access roster: practice management, imaging, email, scheduling, remote access, and any shared credentials the person knew.\n\nWhy: For-cause separations carry the highest risk of retaliatory access; immediate revocation removes the opportunity entirely.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Revoke all system access immediately, before the conversation ends if possible",
          "why": "For-cause separations carry the highest risk of retaliatory access; immediate revocation removes the opportunity entirely."
        },
        {
          "detail": "Collect: building keys, access badges/fobs, any practice-owned laptop/tablet/phone, and confirm garage/alarm codes known to the departing person are changed if shared (not unique).",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Recover physical access and devices"
        },
        {
          "detail": "Rotate passwords on any shared or service accounts, WiFi passphrases, or door codes the departing person knew - individual named accounts are disabled, not reset.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Reset any shared credentials the person had access to"
        },
        {
          "detail": "The compliance officer reviews the deprovisioning checklist against the master access roster and signs off that every system the person had access to shows the account disabled, before the separation file is closed.\n\nWhy: A checklist self-reported as complete by the same person doing the revoking is the weak point; an independent compliance check catches the one system that was missed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms full revocation before the file closes.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms full revocation before the file closes",
          "why": "A checklist self-reported as complete by the same person doing the revoking is the weak point; an independent compliance check catches the one system that was missed."
        },
        {
          "detail": "Record separation date, systems revoked, physical items recovered, credentials rotated, and the compliance officer's sign-off date.\n\nRecord: Deprovisioning log (name, separation date, systems revoked, items recovered, sign-off)",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the deprovisioning"
        },
        {
          "detail": "Deprovisioning complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Deprovisioning complete"
        },
        {
          "detail": "Disable the account at close of business on the confirmed last day, and revoke any remote access earlier if the role does not require it during the notice period.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Schedule revocation for end of the last scheduled day"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Same-day system and facility access revocation at separation — An employee's last day arrives, a termination happens without notice, or a contractor engagement ends.",
      "title": "Same-day system and facility access revocation at separation",
      "trigger": "An employee's last day arrives, a termination happens without notice, or a contractor engagement ends",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-63B Digital Identity Guidelines: Authentication and Lifecycle Management - public domain",
          "source": "NIST SP 800-63B Digital Identity Guidelines: Authentication and Lifecycle Management - public domain",
          "url": "https://pages.nist.gov/800-63-3/sp800-63b.html"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 30,
      "frequency": "quarterly",
      "id": "itd-005",
      "kind": "operational",
      "materials": [
        "master access roster",
        "MFA enrollment report from each system",
        "written password policy"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Export the active account list from the practice management system, email, imaging software, and any remote-access or cloud tool.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Pull the account list for every system in scope"
        },
        {
          "detail": "For each account, confirm MFA is enabled and using an approved method (authenticator app or hardware key preferred over SMS where the system supports it).",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check MFA enrollment for every active account"
        },
        {
          "detail": "Are any active accounts missing MFA?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "none",
              "label": "All accounts have MFA enrolled"
            },
            {
              "goto": "s8",
              "id": "gaps",
              "label": "One or more accounts lack MFA"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Are any active accounts missing MFA?"
        },
        {
          "detail": "Confirm system-enforced password complexity meets the written policy and that no account is still on a vendor-default or never-rotated password past the policy's maximum age.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check password policy compliance"
        },
        {
          "detail": "Was a new system added this quarter?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no",
              "label": "No new system this quarter"
            },
            {
              "goto": "s9",
              "id": "yes",
              "label": "A new system was onboarded"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Was a new system added this quarter?"
        },
        {
          "detail": "Record MFA coverage percentage, any accounts remediated, and password policy compliance status.\n\nRecord: Quarterly MFA/password audit log",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the quarterly check"
        },
        {
          "detail": "Quarterly check complete",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Quarterly check complete"
        },
        {
          "detail": "Enable MFA enforcement for the gap accounts and walk the user through enrollment before the account is used again.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Enroll the missing accounts and follow up with the user"
        },
        {
          "detail": "For any newly onboarded system, verify MFA and the password policy are enabled before any account on it is used for production work.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Confirm MFA and password policy are configured before go-live"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "MFA and password policy enforcement check — Quarterly and on every new system.",
      "title": "MFA and password policy enforcement check",
      "trigger": "Quarterly and on every new system",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "CISA phishing guidance and HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "source": "CISA phishing guidance and HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "url": "https://www.cisa.gov/topics/cyber-threats-and-advisories/nation-state-cyber-actors/phishing"
        },
        {
          "kind": "regulation",
          "label": "HHS Breach Notification Rule 45 CFR 164.400-414",
          "source": "HHS Breach Notification Rule 45 CFR 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-D"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "itd-006",
      "kind": "operational",
      "materials": [
        "email security/quarantine console",
        "incident log",
        "password reset tool"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "all-staff",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Forward or report the suspicious email to IT/the office manager using the designated reporting channel without clicking any link, opening any attachment, or replying.\n\nWhy: The single highest-leverage action any employee can take is not engaging with the message at all; reporting fast is more valuable than analyzing it themselves.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Do not click links or open attachments; report immediately",
          "why": "The single highest-leverage action any employee can take is not engaging with the message at all; reporting fast is more valuable than analyzing it themselves."
        },
        {
          "detail": "Did the reporter (or anyone) already click a link or enter credentials on the page it led to?",
          "forks": [
            {
              "advised": false,
              "goto": "s7",
              "id": "credentials",
              "label": "Yes - credentials or other information were entered on the page"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "noaction",
              "label": "No - reported without clicking or entering anything"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "all-staff",
          "title": "Did the reporter (or anyone) already click a link or enter credentials on the page it led to?"
        },
        {
          "detail": "Pull the message from other inboxes it was sent to, quarantine the sender domain, and confirm whether it is a known phishing pattern (spoofed sender, urgent payment/credential request, look-alike domain).",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Isolate and analyze the message"
        },
        {
          "detail": "Remove the message from every mailbox it reached across the organization and block the sending domain at the email gateway.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Purge the message from all mailboxes"
        },
        {
          "detail": "Send a brief internal notice describing what the phishing message looked like so other staff recognize it if it recurs, without shaming the original reporter.\n\nWhy: A blameless, fast internal notice is what keeps future reports coming quickly instead of staff hiding a mistake.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify staff of the pattern",
          "why": "A blameless, fast internal notice is what keeps future reports coming quickly instead of staff hiding a mistake."
        },
        {
          "detail": "Phishing incident closed",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Phishing incident closed"
        },
        {
          "detail": "Force a password reset and sign the account out of all active sessions on every system that shared that password, and re-verify MFA enrollment on the account.\n\nWhy: A credential entered on a look-alike page is compromised the moment it is typed; the account must be treated as taken over until proven otherwise.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Immediately reset the affected account's credentials and revoke active sessions",
          "why": "A credential entered on a look-alike page is compromised the moment it is typed; the account must be treated as taken over until proven otherwise."
        },
        {
          "detail": "Check login history, email forwarding rules, and file access logs on the compromised account for the period since the credential entry for signs of unauthorized use.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Review the account's recent activity for unauthorized access"
        },
        {
          "detail": "Because the compromised account had access to systems containing patient records, the compliance officer opens a formal breach risk assessment per the HIPAA breach-analysis protocol before any notification decision is made - this determination is never made unilaterally by IT.\n\nWhy: Whether a credential compromise rises to a reportable breach is a compliance determination with regulatory consequences, not a technical one - it must go through a named decision-maker.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer opens the breach risk assessment.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer opens the breach risk assessment",
          "why": "Whether a credential compromise rises to a reportable breach is a compliance determination with regulatory consequences, not a technical one - it must go through a named decision-maker."
        },
        {
          "detail": "Record the report time, containment actions taken, whether credentials were compromised, and whether a breach assessment was opened.\n\nRecord: Phishing incident log (report time, actions, credential status, breach assessment opened Y/N)",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the incident"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Staff reports a phishing or suspicious email, or entered credentials on a look-alike page — A report is received — do not click, isolate, verify, purge, reset credentials, notify; a credential entry triggers the breach assessment.",
      "title": "Staff reports a phishing or suspicious email, or entered credentials on a look-alike page",
      "trigger": "A report is received — do not click, isolate, verify, purge, reset credentials, notify; a credential entry triggers the breach assessment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "CISA #StopRansomware guide",
          "source": "CISA #StopRansomware guide",
          "url": "https://www.cisa.gov/stopransomware"
        },
        {
          "kind": "regulation",
          "label": "HHS ransomware fact sheet and HHS Breach Notification Rule 45 CFR 164.400-414",
          "source": "HHS ransomware fact sheet and HHS Breach Notification Rule 45 CFR 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-D"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "itd-007",
      "kind": "operational",
      "materials": [
        "network isolation procedure (unplug/disable WiFi)",
        "clean verified backup",
        "incident response contact list (IT vendor, legal, cyber-insurance carrier, law enforcement)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "practice-owner",
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Disconnect the affected device(s) from the network (unplug ethernet, disable WiFi) without shutting them down, and disconnect other systems on the same network segment as a precaution.\n\nWhy: Ransomware spreads laterally across a network in minutes; isolation is the single action that limits how much gets encrypted, and it must happen before anything else.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Isolate affected systems from the network immediately",
          "why": "Ransomware spreads laterally across a network in minutes; isolation is the single action that limits how much gets encrypted, and it must happen before anything else."
        },
        {
          "detail": "Leave isolated systems powered on (unless actively encrypting more data) - forensic evidence and encryption keys can be lost on shutdown. Do not attempt to pay a ransom, negotiate, or run removal tools before the next steps.\n\nWhy: Premature cleanup can destroy the evidence needed for the breach assessment and any law-enforcement or insurance claim.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Do not power off or attempt to remove the malware yet",
          "why": "Premature cleanup can destroy the evidence needed for the breach assessment and any law-enforcement or insurance claim."
        },
        {
          "detail": "Call the practice owner directly (do not rely on email, which may be compromised) and describe what is observed: which systems, what the notice/alert says, and whether patient-record systems appear affected.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Notify the practice owner immediately"
        },
        {
          "detail": "Activate the practice-software/network outage downtime procedure (itd-008) so patient care can continue without the affected systems while recovery proceeds.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Switch to the downtime paper workflow"
        },
        {
          "detail": "Document which systems are affected, take photos/screenshots of ransom notes or alerts without interacting with any links they contain, and identify whether backups are also reachable from the affected network (and therefore possibly at risk).",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Preserve evidence and identify the scope"
        },
        {
          "detail": "The practice owner, with the compliance officer, decides whether to engage the cyber-insurance carrier, outside incident-response counsel, and/or law enforcement before recovery proceeds; ransom payment is never authorized at the IT-vendor level.\n\nWhy: These are decisions with legal, financial and regulatory weight that belong to the practice owner, not to whoever is closest to the keyboard when the alert fires.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner and compliance officer decide on outside engagement.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner and compliance officer decide on outside engagement",
          "why": "These are decisions with legal, financial and regulatory weight that belong to the practice owner, not to whoever is closest to the keyboard when the alert fires."
        },
        {
          "detail": "Verify the most recent backup predates the infection and was not reachable from the compromised network segment (an offline or immutable backup is ideal); do not restore from a backup that may itself be compromised.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Confirm a clean, unaffected backup exists"
        },
        {
          "detail": "Wipe and rebuild infected machines from a known-clean image, then restore data from the verified clean backup rather than attempting to 'clean' an infected system in place.\n\nWhy: Partially cleaned systems can retain a foothold; a rebuild-and-restore is the only approach that reliably removes persistence mechanisms.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Rebuild affected systems and restore from the clean backup",
          "why": "Partially cleaned systems can retain a foothold; a rebuild-and-restore is the only approach that reliably removes persistence mechanisms."
        },
        {
          "detail": "Because the affected systems held or could reach patient records, the compliance officer opens a formal breach risk assessment (per the HIPAA breach-analysis protocol) covering scope, likelihood of data access, and notification obligations, before any public or patient-facing statement is made.\n\nWhy: Ransomware on a system with PHI is presumed reportable under HHS guidance until an assessment says otherwise; this determination is a compliance call, never a technical or PR one.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer opens the breach risk assessment.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer opens the breach risk assessment",
          "why": "Ransomware on a system with PHI is presumed reportable under HHS guidance until an assessment says otherwise; this determination is a compliance call, never a technical or PR one."
        },
        {
          "detail": "Record detection time, isolation time, systems affected, restore completion time, total downtime, and outside parties engaged, for the incident file and any insurance/regulatory filing.\n\nRecord: Ransomware incident timeline log",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the full incident timeline"
        },
        {
          "detail": "Incident contained and recovery complete",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Incident contained and recovery complete"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Suspected ransomware or malware — first hour, containment and recovery — An encryption notice, locked files or an endpoint alert appears — isolate, preserve, escalate, restore from backup, begin the breach risk assessment.",
      "title": "Suspected ransomware or malware — first hour, containment and recovery",
      "trigger": "An encryption notice, locked files or an endpoint alert appears — isolate, preserve, escalate, restore from backup, begin the breach risk assessment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management, audit controls, device and media controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "itd-008",
      "kind": "operational",
      "materials": [
        "printed downtime schedule/appointment list",
        "paper chart/encounter forms",
        "backup card-processing method (offline terminal or manual imprint)",
        "internet failover (hotspot/secondary ISP) if available"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "front-desk",
        "office-manager",
        "dentist",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm whether the practice management system, network, or internet connectivity is down (not just one workstation) and notify the office manager immediately.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the outage and notify the office manager"
        },
        {
          "detail": "Is this a local issue (one device/router) or a wider outage (ISP/cloud vendor)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "local",
              "label": "Local device or router issue"
            },
            {
              "goto": "s6",
              "id": "wider",
              "label": "Wider ISP or cloud vendor outage"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Is this a local issue (one device/router) or a wider outage (ISP/cloud vendor)?"
        },
        {
          "detail": "Restart the affected router/device and confirm restoration; if resolved within a few minutes, notify the office manager and skip the downtime workflow.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Attempt a quick local fix"
        },
        {
          "detail": "Is the system now working normally?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "yes",
              "label": "Restored"
            },
            {
              "goto": "s7",
              "id": "no",
              "label": "Still down"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Is the system now working normally?"
        },
        {
          "detail": "Outage resolved and records reconciled",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Outage resolved and records reconciled"
        },
        {
          "detail": "Switch to a backup internet connection (mobile hotspot or secondary ISP) if one is available, and check the cloud vendor's status page for an estimated restoration time.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check the failover connection"
        },
        {
          "detail": "Print today's remaining appointment schedule (if not already printed at the start of day per routine practice) and switch front desk and clinical charting to paper encounter forms.\n\nWhy: Patient care and scheduling cannot pause for an outage; the paper fallback exists precisely so the day continues.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Activate the paper downtime workflow",
          "why": "Patient care and scheduling cannot pause for an outage; the paper fallback exists precisely so the day continues."
        },
        {
          "detail": "Use the offline card terminal or manual imprint/authorization method for payment collection while the primary processor is unreachable; hold receipts for reconciliation once systems return.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Switch card processing to the backup method"
        },
        {
          "detail": "Record clinical notes, treatment performed, and any prescriptions on paper forms exactly as they would be entered digitally, for later transcription.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Chart on paper encounter forms during the outage"
        },
        {
          "detail": "Queue insurance claims and electronic prescriptions to be submitted once connectivity is restored; for any prescription that cannot wait, use the practice's paper/phone prescribing fallback per clinical policy.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Hold e-claims and e-prescribing until systems return"
        },
        {
          "detail": "Check the system or ISP/cloud vendor status every 15 minutes until service is restored.",
          "id": "s11",
          "kind": "timer",
          "role": "it-vendor",
          "timer_seconds": 900,
          "title": "Monitor for restoration"
        },
        {
          "detail": "Has service been restored?",
          "forks": [
            {
              "goto": "s11",
              "id": "no",
              "label": "Still down"
            },
            {
              "advised": true,
              "goto": "s13",
              "id": "yes",
              "label": "Service restored"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Has service been restored?"
        },
        {
          "detail": "Enter all paper encounter forms, payments, claims and prescriptions from the outage period into the practice management system, cross-checking each against the paper form before marking it entered.\n\nWhy: Paper-to-digital reconciliation is where a rushed entry silently drops or duplicates a record; checking each item against its paper source catches that before it becomes a billing or clinical gap.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Reconcile paper records into the digital system",
          "why": "Paper-to-digital reconciliation is where a rushed entry silently drops or duplicates a record; checking each item against its paper source catches that before it becomes a billing or clinical gap."
        },
        {
          "detail": "Once reconciliation is confirmed complete, secure the paper forms per the practice's document retention policy or destroy them per its PHI disposal procedure.",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Secure or destroy paper downtime forms per retention policy"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Practice software, network or internet outage — paper workflow and recovery — A core system, the network or connectivity is unavailable during patient hours and cloud systems, e-claims, e-prescribing and card processing stop.",
      "title": "Practice software, network or internet outage — paper workflow and recovery",
      "trigger": "A core system, the network or connectivity is unavailable during patient hours and cloud systems, e-claims, e-prescribing and card processing stop",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule contingency planning — 45 CFR 164.308(a)(7)",
          "source": "HIPAA Security Rule contingency planning — 45 CFR 164.308(a)(7)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "HHS 405(d) Health Industry Cybersecurity Practices (public domain)",
          "source": "HHS 405(d) Health Industry Cybersecurity Practices (public domain)",
          "url": "https://405d.hhs.gov/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "itd-009",
      "kind": "operational",
      "materials": [
        "backup cell number posted for staff",
        "phone/internet provider outage line",
        "website and voicemail-greeting update access",
        "call-forwarding setup instructions"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Call the practice's main line from a personal cell phone; check whether the desk handset shows a dial tone, an error message, or is completely dead. Note whether voicemail also fails.\n\nWhy: A single dead handset is a device problem; a dead dial tone across every line is a carrier or system outage that needs a different response.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the phones are actually down, not just quiet",
          "why": "A single dead handset is a device problem; a dead dial tone across every line is a carrier or system outage that needs a different response."
        },
        {
          "detail": "Check whether internet and other cloud services are also down (a shared-internet phone system fails with the internet). Call the phone/internet provider's outage line for a known-issue confirmation.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "carrier-side",
              "label": "Provider confirms a known outage in the area"
            },
            {
              "goto": "s9",
              "id": "onsite-equipment",
              "label": "Provider reports no outage — likely on-site router, ATA or handset failure"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Determine whether the outage is carrier-side or on-site equipment"
        },
        {
          "detail": "Forward the main number to the designated staff cell phone if call-forwarding still routes, or begin directing walk-ins and known callbacks through the backup cell number posted at the front desk.\n\nWhy: Patients calling about pain or a same-day problem cannot be left with no way to reach the office.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Activate the posted backup contact channel",
          "why": "Patients calling about pain or a same-day problem cannot be left with no way to reach the office."
        },
        {
          "detail": "If voicemail is reachable, record a short greeting naming the temporary contact method; if the practice website or online listings can be edited quickly, add a one-line outage notice with the backup number.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the voicemail greeting and website banner with the temporary number"
        },
        {
          "detail": "Open a formal outage ticket, get a ticket number and an estimated restoration time, and check back at the estimated time if not restored.\n\nRecord: outage ticket number, provider, estimated restoration time",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Escalate with the phone/internet provider and log a ticket"
        },
        {
          "detail": "Test inbound and outbound calls on every line and confirm voicemail is recording again before removing the temporary forwarding or website banner.\n\nWhy: Reverting the backup channel too early can strand a caller mid-outage if restoration is only partial.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Verify full restoration before reverting the backup channel",
          "why": "Reverting the backup channel too early can strand a caller mid-outage if restoration is only partial."
        },
        {
          "detail": "Record start/end time, cause if known, calls handled via backup channel, and provider ticket number in the IT incident log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the outage"
        },
        {
          "detail": "Phone outage closed out",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Phone outage closed out"
        },
        {
          "detail": "Give the IT vendor the exact symptoms (which lines, whether internet is up, any error codes shown), and confirm they can remote in or need to come on site.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the IT vendor for on-site equipment triage"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Phone system or number outage — Incoming calls fail, voicemail is dead, or the ported number stops ringing.",
      "title": "Phone system or number outage",
      "trigger": "Incoming calls fail, voicemail is dead, or the ported number stops ringing",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule device and media controls — 45 CFR 164.310(d)",
          "source": "HIPAA Security Rule device and media controls — 45 CFR 164.310(d)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "HHS Breach Notification Rule — 45 CFR 164.400-414",
          "source": "HHS Breach Notification Rule — 45 CFR 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-D"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 HIPAA security implementation guide (public domain)",
          "source": "NIST SP 800-66 HIPAA security implementation guide (public domain)",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "itd-010",
      "kind": "operational",
      "materials": [
        "mobile device management or remote-wipe console access",
        "device inventory list with encryption status",
        "police report form or non-emergency line",
        "breach risk assessment worksheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "it-vendor",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Tell the office manager or IT vendor as soon as a device cannot be located — do not spend the day searching before reporting; every hour unreported is an hour the device could be accessed.\n\nWhy: The wipe-and-lock window closes the moment someone else has meaningful time with the device.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Report the missing or stolen device immediately, do not wait",
          "why": "The wipe-and-lock window closes the moment someone else has meaningful time with the device."
        },
        {
          "detail": "Use the mobile device management console or platform's find-my-device tool to lock the device, wipe it if it does not check in within a short window, and revoke its access tokens and app sessions.\n\nWhy: A remote wipe before the device is powered off or has its SIM pulled is the single most effective control available.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Attempt a remote lock and wipe immediately",
          "why": "A remote wipe before the device is powered off or has its SIM pulled is the single most effective control available."
        },
        {
          "detail": "Confirm from the device inventory record whether full-disk or device-level encryption was enabled and whether the device was password/PIN or biometric locked.\n\nRecord: device id, encryption status, lock status, last-known access date",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check whether the device was encrypted at rest"
        },
        {
          "detail": "File a report for any suspected theft (as opposed to simple misplacement) and for any device likely to hold PHI, regardless of recovery odds.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "file-report",
              "label": "File a police report and record the report number"
            },
            {
              "goto": "s5",
              "id": "no-report-misplaced",
              "label": "Continue as misplaced only if recovered on-site before any exposure window elapsed"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide whether to file a police report"
        },
        {
          "detail": "A lost or stolen device that could access PHI always opens a formal breach risk assessment — encryption status, what data was accessible, and whether the device checked in after loss all feed the determination; the assessment itself, and any resulting notification, is never auto-closed by IT alone.\n\nWhy: Whether this becomes a reportable breach is a compliance determination with regulatory notification consequences, not an IT ticket outcome.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer opens the breach risk assessment before any final determination.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer opens the breach risk assessment before any final determination",
          "why": "Whether this becomes a reportable breach is a compliance determination with regulatory notification consequences, not an IT ticket outcome."
        },
        {
          "detail": "Force a password reset on any account the device was logged into, revoke active sessions and re-issue MFA tokens if the device held an authenticator.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Reset credentials and revoke sessions tied to the device"
        },
        {
          "detail": "Summarize what happened, the encryption/lock status, whether a police report was filed, and the current state of the breach risk assessment.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the practice owner of the incident and assessment status"
        },
        {
          "detail": "Record device id, loss circumstances, encryption status, wipe confirmation, police report number if any, and the breach risk assessment conclusion in the compliance incident log.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident and assessment outcome"
        },
        {
          "detail": "Lost/stolen device incident closed out",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Lost/stolen device incident closed out"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Lost or stolen laptop, tablet, phone or backup drive — A device that may hold or access PHI cannot be located or is reported stolen — remote wipe, then the breach assessment.",
      "title": "Lost or stolen laptop, tablet, phone or backup drive",
      "trigger": "A device that may hold or access PHI cannot be located or is reported stolen — remote wipe, then the breach assessment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "NIST SP 800-88 Rev. 1 Guidelines for Media Sanitization (public domain)",
          "source": "NIST SP 800-88 Rev. 1 Guidelines for Media Sanitization (public domain)",
          "url": "https://csrc.nist.gov/pubs/sp/800/88/r1/final"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule device and media controls — 45 CFR 164.310(d)",
          "source": "HIPAA Security Rule device and media controls — 45 CFR 164.310(d)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "itd-011",
      "kind": "operational",
      "materials": [
        "media sanitization checklist",
        "certificate-of-destruction template",
        "asset inventory system access",
        "data-wipe or degaussing tool"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note the device type, asset tag, current user or location, and what data it may hold — including copier and scanner hard drives, which are often overlooked.\n\nWhy: Multi-function copiers and scanners store an internal disk of every document processed and are a common blind spot in retirement checklists.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the device being retired or reassigned and pull its inventory record",
          "why": "Multi-function copiers and scanners store an internal disk of every document processed and are a common blind spot in retirement checklists."
        },
        {
          "detail": "Choose Clear (software overwrite), Purge (cryptographic erase or degauss), or Destroy (physical shredding) based on the device's data sensitivity and whether it is leaving the practice's control.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "purge-or-destroy",
              "label": "Purge or Destroy — device is leaving practice control or held PHI on unencrypted media"
            },
            {
              "goto": "s3",
              "id": "clear-for-internal-reuse",
              "label": "Clear — device stays inside the practice for internal reuse only"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Classify the required sanitization method by NIST SP 800-88 category"
        },
        {
          "detail": "Run the chosen method to completion and verify — spot-check a sample sector or confirm the tool's own completion report — before treating the device as clean.\n\nWhy: An interrupted wipe that is assumed complete leaves residual data on a device about to leave the building.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Perform the sanitization and verify it completed",
          "why": "An interrupted wipe that is assumed complete leaves residual data on a device about to leave the building."
        },
        {
          "detail": "Data wiped or destroyed per the classified method; device removed from all remote-access and MDM enrollment; associated accounts logged out and de-authorized; any local backup of the device's data is either transferred or also disposed of per policy.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Confirm every sanitization step before sign-off"
        },
        {
          "detail": "Confirm the method used matched the data sensitivity classification and sign the sanitization or destruction certificate for the device.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review and sign the certificate of destruction or sanitization record"
        },
        {
          "detail": "Mark the device retired, reassigned or destroyed in the asset inventory, with date, method used, and who performed and who witnessed the sanitization.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Update the asset inventory"
        },
        {
          "detail": "Device retirement closed out",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Device retirement closed out"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Device retirement, reuse and media sanitization with inventory update — A workstation, phone, copier, sensor laptop, drive or imaging unit is retired or reassigned.",
      "title": "Device retirement, reuse and media sanitization with inventory update",
      "trigger": "A workstation, phone, copier, sensor laptop, drive or imaging unit is retired or reassigned",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule minimum necessary and safeguards — 45 CFR 164.502, 164.530(c)",
          "source": "HIPAA Privacy Rule minimum necessary and safeguards — 45 CFR 164.502, 164.530(c)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "HHS Breach Notification Rule — 45 CFR 164.400-414",
          "source": "HHS Breach Notification Rule — 45 CFR 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-D"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "itd-012",
      "kind": "operational",
      "materials": [
        "fax cover sheet with confidentiality notice",
        "misdirected-transmission log",
        "recipient verification (speed-dial list, confirmed email addresses)",
        "breach risk assessment worksheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "it-vendor",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Printed documents are retrieved from shared printers immediately, not left in an output tray; fax numbers are verified against the practice's confirmed recipient list before sending; scanned documents route to a secured folder, not an open shared drive; every outgoing fax carries the confidentiality cover sheet.\n\nWhy: Most misdirected-PHI incidents are prevented at the point of send, not caught after the fact.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Daily PHI-bearing device handling routine",
          "why": "Most misdirected-PHI incidents are prevented at the point of send, not caught after the fact."
        },
        {
          "detail": "Someone notices a fax, email, text or printout went to the wrong patient, office, or number — either self-caught or reported by the unintended recipient.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "misdirection-confirmed",
              "label": "Confirmed misdirected transmission containing patient information"
            },
            {
              "goto": "s8",
              "id": "false-alarm",
              "label": "False alarm — verified it reached the correct, intended recipient"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "A misdirected transmission is discovered or reported"
        },
        {
          "detail": "If a fax or print job is still queued, cancel it; keep a copy of exactly what was sent and to what number, address or fax line for the record.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Stop further transmission and preserve what was sent"
        },
        {
          "detail": "Call or email the wrong recipient, explain the item was sent in error, and ask them to destroy the paper copy or delete the electronic copy; document their confirmation if given.\n\nWhy: Prompt request for destruction limits further exposure and is a factor in the breach risk assessment.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Contact the unintended recipient and request destruction or deletion",
          "why": "Prompt request for destruction limits further exposure and is a factor in the breach risk assessment."
        },
        {
          "detail": "Every confirmed misdirected transmission of patient information triggers a documented breach risk assessment — what data, how much, who received it, and whether it was mitigated — regardless of how minor it appears.\n\nWhy: A misdirected single-page referral and a misdirected full chart both require the same formal determination process; severity is assessed, not assumed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer opens the breach risk assessment.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer opens the breach risk assessment",
          "why": "A misdirected single-page referral and a misdirected full chart both require the same formal determination process; severity is assessed, not assumed."
        },
        {
          "detail": "Confirm whether the wrong number/address was a manual entry error, a stale speed-dial entry, or an autocomplete mistake in email/fax software, and correct the source if systemic.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check for a systemic cause"
        },
        {
          "detail": "Record what was sent, to whom in error, recipient contact outcome, root cause, and the breach risk assessment conclusion in the misdirected-transmission log.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident and assessment outcome"
        },
        {
          "detail": "Misdirected transmission closed out",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Misdirected transmission closed out"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Printer, fax and scanner PHI handling, and misdirected fax, email or text response — Daily handling; a referral, statement, radiograph or message went to the wrong patient, office or number.",
      "title": "Printer, fax and scanner PHI handling, and misdirected fax, email or text response",
      "trigger": "Daily handling; a referral, statement, radiograph or message went to the wrong patient, office or number",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule technical safeguards — access control, 45 CFR 164.312(a)",
          "source": "HIPAA Security Rule technical safeguards — access control, 45 CFR 164.312(a)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 HIPAA security implementation guide (public domain)",
          "source": "NIST SP 800-66 HIPAA security implementation guide (public domain)",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 45,
      "frequency": "quarterly",
      "id": "itd-013",
      "kind": "operational",
      "materials": [
        "network diagram or VLAN documentation",
        "guest wifi password rotation log",
        "firewall/router admin access",
        "segmentation test checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm which subnet or VLAN each device category belongs to: clinical workstations and imaging systems, front-desk/administrative devices, and guest wifi.\n\nWhy: The check is only meaningful against a documented baseline of how the network is supposed to be segmented.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Pull the current network diagram or VLAN documentation",
          "why": "The check is only meaningful against a documented baseline of how the network is supposed to be segmented."
        },
        {
          "detail": "Connect a test device to guest wifi and attempt to reach a clinical-segment IP address (imaging server, practice-management server); confirm the attempt is blocked at the firewall or VLAN boundary.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Test that guest wifi cannot reach the clinical network segment"
        },
        {
          "detail": "Confirm every device on the clinical VLAN is an authorized clinical or administrative asset from the inventory; no personal phones, smart TVs, or unknown devices are present.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Audit devices on the clinical segment"
        },
        {
          "detail": "Confirm when the guest wifi password was last rotated against the rotation policy; rotate it now if overdue.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check guest wifi password age and rotate if due"
        },
        {
          "detail": "Weigh the isolation test result and device audit findings.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "segmentation-intact",
              "label": "Segmentation intact, guest wifi isolated, all clinical-segment devices authorized"
            },
            {
              "goto": "s8",
              "id": "needs-remediation",
              "label": "Isolation failed or an unauthorized device was found on the clinical segment"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Decide whether segmentation is intact or needs remediation"
        },
        {
          "detail": "Record the date, test results, any devices found and remediation taken, and the guest password rotation date in the network review log.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the quarterly check"
        },
        {
          "detail": "Quarterly network segmentation check closed out",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Quarterly network segmentation check closed out"
        },
        {
          "detail": "Correct the firewall/VLAN rule or move the unauthorized device off the clinical segment, then repeat the isolation test to confirm the fix holds.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Remediate and retest before closing the check"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Guest wifi and clinical network segmentation check — The quarterly network review, or a new device or guest access point is added.",
      "title": "Guest wifi and clinical network segmentation check",
      "trigger": "The quarterly network review, or a new device or guest access point is added",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule access control and transmission security — 45 CFR 164.312(a), (e)",
          "source": "HIPAA Security Rule access control and transmission security — 45 CFR 164.312(a), (e)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 HIPAA security implementation guide (public domain)",
          "source": "NIST SP 800-66 HIPAA security implementation guide (public domain)",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "itd-014",
      "kind": "operational",
      "materials": [
        "remote access request form",
        "personal-device (BYOD) policy acknowledgment",
        "MFA enrollment instructions",
        "VPN or secure remote-access client"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note who is requesting access, what system they need to reach (practice-management, email, imaging), and whether it is from a practice-owned device, a personal device, or both.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Receive and log the remote or personal-device access request"
        },
        {
          "detail": "Check the requested access against the practice's remote-access and personal-device policy — some roles (e.g. billing working from home) are pre-approved, others require case-by-case sign-off.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "eligible",
              "label": "Role is pre-approved for this type of remote access"
            },
            {
              "goto": "s8",
              "id": "not-pre-approved",
              "label": "Not pre-approved — escalate for a case-by-case decision"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Confirm the role is eligible for the requested access under policy"
        },
        {
          "detail": "The team member reviews and signs the policy covering PHI handling, encryption requirements, prohibited actions (no PHI to personal cloud storage or unencrypted local saves), and consequences of violation, before any access is provisioned.\n\nWhy: Access without a documented, understood policy commitment leaves the practice unable to show reasonable safeguards were in place.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Team member signs the remote-access or personal-device policy acknowledgment.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Team member signs the remote-access or personal-device policy acknowledgment",
          "why": "Access without a documented, understood policy commitment leaves the practice unable to show reasonable safeguards were in place."
        },
        {
          "detail": "Screen lock/passcode enabled; device encryption enabled; current operating system security updates installed; approved antivirus/endpoint protection installed if it is a personal device.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Confirm the device meets minimum security requirements before granting access"
        },
        {
          "detail": "Set up the VPN or secure remote-access client, enroll the account in multi-factor authentication, and grant only the specific systems the role needs — never blanket access.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Provision remote access with MFA and least privilege"
        },
        {
          "detail": "Record who was granted access, what systems, device type, MFA enrollment confirmation, and the signed policy acknowledgment date in the access log.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the remote-access grant"
        },
        {
          "detail": "Remote access policy check closed out",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Remote access policy check closed out"
        },
        {
          "detail": "Summarize the request and the compliance considerations (what PHI would be reachable, from what type of device) for an owner decision before proceeding.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escalate the non-standard request to the practice owner"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Remote access and personal-device policy check — A team member requests remote or personal-device access.",
      "title": "Remote access and personal-device policy check",
      "trigger": "A team member requests remote or personal-device access",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule access control and audit controls — 45 CFR 164.312(a), (b)",
          "repaired": {
            "action": "replace",
            "evidence": "§164.312(a) Access control — Implement technical policies and procedures for electronic information systems that maintain electronic protected health information to allow access only to those persons or software programs that have been granted access rights. §164.312(b) Audit controls — implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA Security Rule access authorization and audit controls — 45 CFR 164.312(b), (d)",
              "url": "https://www.ecfr.gov/current/title-45/part-164"
            }
          },
          "source": "45 CFR 164.312(a) (Access Control) and 164.312(b) (Audit Controls)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.312"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "itd-015",
      "kind": "operational",
      "materials": [
        "vendor support ticket portal or phone line",
        "remote-support session log",
        "screen-share tool with session recording if available",
        "affected-system inventory record"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note exactly what the software was doing when it failed, any error message text or code, and whether the fault affects one workstation or all of them.\n\nWhy: Specific symptoms let the vendor triage faster than a general 'it's not working' report.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Report the software fault with specific symptoms",
          "why": "Specific symptoms let the vendor triage faster than a general 'it's not working' report."
        },
        {
          "detail": "Log the fault through the vendor's support portal or phone line, referencing the equipment model and software version.\n\nRecord: vendor ticket number, equipment/software affected, symptom description",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Open a support ticket with the equipment or software vendor"
        },
        {
          "detail": "Close or minimize any window showing patient images, names, or chart data before granting the vendor remote access; navigate to a blank or non-patient screen first.\n\nWhy: A vendor technician remoting in to fix a software fault does not need to see the patient information that happens to be on screen.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Clear patient information from the screen before any vendor remote session begins",
          "why": "A vendor technician remoting in to fix a software fault does not need to see the patient information that happens to be on screen."
        },
        {
          "detail": "Stay present for the entire remote session rather than leaving the vendor unattended on the workstation; note what actions the vendor takes.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Supervise the vendor's remote session in real time"
        },
        {
          "detail": "Record the vendor name, technician if given, start/end time of the remote session, and a summary of what was changed or fixed, in the remote-support session log.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the remote-support session"
        },
        {
          "detail": "Confirm the remote-access software has disconnected and, if it was a one-time install, is removed or disabled after the session.\n\nWhy: A remote-access tool left running after the fix is an open door into the system.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "End the remote session and verify remote-access tools are fully closed",
          "why": "A remote-access tool left running after the fix is an open door into the system."
        },
        {
          "detail": "Run a test capture or a non-patient function check to confirm the fault is actually resolved before the next patient is scheduled on that equipment.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Verify the equipment or software works as expected before returning to patient use"
        },
        {
          "detail": "Record the resolution, ticket close date, and confirmation of functional verification in the support ticket log.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Close the ticket with resolution notes"
        },
        {
          "detail": "Support ticket closed out",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Support ticket closed out"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Imaging or equipment software support ticket with controlled vendor remote session — A software fault is reported by the clinical team.",
      "title": "Imaging or equipment software support ticket with controlled vendor remote session",
      "trigger": "A software fault is reported by the clinical team",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 HIPAA security implementation guide — asset management (public domain)",
          "source": "NIST SP 800-66 HIPAA security implementation guide — asset management (public domain)",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "HHS 405(d) Health Industry Cybersecurity Practices (public domain)",
          "source": "HHS 405(d) Health Industry Cybersecurity Practices (public domain)",
          "url": "https://405d.hhs.gov/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 60,
      "frequency": "quarterly",
      "id": "itd-016",
      "kind": "operational",
      "materials": [
        "asset inventory spreadsheet or system",
        "physical walkthrough checklist",
        "software license list",
        "device labeling supplies (asset tags)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Open the existing hardware and software inventory list as the starting baseline for the quarterly walkthrough.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Pull the current asset inventory record"
        },
        {
          "detail": "Confirm each workstation, laptop, tablet, phone, imaging unit, network device and backup drive physically present matches an inventory entry; note anything present but not listed, and anything listed but not found.\n\nWhy: A device physically present but missing from inventory is unmanaged and likely unpatched; a device listed but not found may be lost, stolen, or simply moved without a record update.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Walk through every room and count devices against the inventory",
          "why": "A device physically present but missing from inventory is unmanaged and likely unpatched; a device listed but not found may be lost, stolen, or simply moved without a record update."
        },
        {
          "detail": "Confirm the number of active installations of each licensed software product does not exceed what the practice is entitled to, and remove licenses from retired devices.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Reconcile software licenses against entitlements"
        },
        {
          "detail": "Weigh whether an unlisted device needs to be added and secured, or a missing device needs escalation as a possible loss.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "add-and-secure",
              "label": "Add unlisted devices to inventory and confirm they meet baseline security settings"
            },
            {
              "goto": "s7",
              "id": "escalate-missing",
              "label": "Escalate a device listed but not found as a possible lost/stolen device"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Decide how to resolve discrepancies found"
        },
        {
          "detail": "Record the walkthrough date, every addition, removal and correction made, and the software license reconciliation result in the asset inventory system.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Update and save the reconciled inventory"
        },
        {
          "detail": "Quarterly asset inventory closed out",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Quarterly asset inventory closed out"
        },
        {
          "detail": "Route the missing device to the lost-or-stolen-device process (itd-010) rather than simply removing it from inventory, since it may hold PHI.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand off to the lost-or-stolen-device protocol"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Hardware and software asset inventory update — The quarterly inventory date arrives, or a device is added, moved or retired.",
      "title": "Hardware and software asset inventory update",
      "trigger": "The quarterly inventory date arrives, or a device is added, moved or retired",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308(a)(5) - security awareness and training",
          "source": "HIPAA Security Rule 45 CFR 164.308(a)(5) - security awareness and training",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "CISA / HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "source": "CISA / HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "url": "https://405d.hhs.gov/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 60,
      "frequency": "annual",
      "id": "itd-017",
      "kind": "operational",
      "materials": [
        "security awareness training module or course",
        "simulated phishing campaign tool",
        "training completion tracker",
        "written security policy acknowledgment form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "hr",
        "all-staff",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Enroll each new hire in the security awareness training module (phishing recognition, password hygiene, PHI handling on IT systems, device and remote-access rules) before or during their first week, regardless of role.\n\nWhy: A new hire without training is the single easiest target for a phishing test, real or otherwise, because they have not yet learned the practice's normal communication patterns.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Assign security awareness training to every new hire in the first week",
          "why": "A new hire without training is the single easiest target for a phishing test, real or otherwise, because they have not yet learned the practice's normal communication patterns."
        },
        {
          "detail": "Set the annual training date on the compliance calendar and notify all staff at least two weeks ahead with the completion deadline.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the annual refresher for all staff"
        },
        {
          "detail": "Each staff member completes the training covering phishing/social-engineering recognition, password and MFA practices, safe handling of systems containing patient records, device policy, and incident reporting steps.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Complete the training module"
        },
        {
          "detail": "Cross-check the training completion tracker against the current staff roster; identify anyone who has not completed the module by the deadline.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Track completion against the full staff roster"
        },
        {
          "detail": "Did everyone complete training by the deadline?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "All staff completed on time"
            },
            {
              "goto": "s11",
              "id": "no",
              "label": "One or more staff have not completed it"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did everyone complete training by the deadline?"
        },
        {
          "detail": "Send a realistic but harmless simulated phishing email to all staff at an unannounced time, using a pattern similar to real threats seen in the industry (urgent request, look-alike domain, credential harvest link).\n\nWhy: Training that is never tested tells you what staff were taught, not what they will actually do when a real message arrives.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Run the simulated phishing campaign",
          "why": "Training that is never tested tells you what staff were taught, not what they will actually do when a real message arrives."
        },
        {
          "detail": "Record who clicked the simulated link, who entered any information, and who reported the message correctly per the phishing-report protocol (itd-006).",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Score the simulation results"
        },
        {
          "detail": "Did anyone click the link or enter information in the simulation?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "no",
              "label": "No one clicked or entered information"
            },
            {
              "goto": "s12",
              "id": "yes",
              "label": "One or more staff clicked or entered information"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did anyone click the link or enter information in the simulation?"
        },
        {
          "detail": "Record training completion rate, simulation click rate, simulation report rate, and any follow-up coaching provided, in the compliance training file.\n\nRecord: Annual security awareness training and phishing simulation log (completion %, click rate, report rate, follow-up)",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the training and simulation cycle"
        },
        {
          "detail": "Annual training and simulation cycle complete",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual training and simulation cycle complete"
        },
        {
          "detail": "Send a direct reminder with a short grace period; a staff member who still does not complete training may have non-essential system access limited until they do, at the office manager's discretion.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Follow up with outstanding staff"
        },
        {
          "detail": "Meet individually with anyone who clicked or entered information in the simulation, walk through what the warning signs were, and schedule a short refresher; this is coaching, not a disciplinary action for a first occurrence.\n\nWhy: A punitive response to a simulation teaches staff to hide a real click rather than report it - the opposite of what itd-006 depends on.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Provide targeted follow-up coaching, not discipline",
          "why": "A punitive response to a simulation teaches staff to hide a real click rather than report it - the opposite of what itd-006 depends on."
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Annual security awareness training and phishing simulation — Annually and at hire.",
      "title": "Annual security awareness training and phishing simulation",
      "trigger": "Annually and at hire",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 (electronic claims/eligibility transactions)",
          "source": "HIPAA transaction standards 45 CFR Part 162 (electronic claims/eligibility transactions)",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "itd-018",
      "kind": "operational",
      "materials": [
        "vendor status page bookmarks",
        "vendor support contact list",
        "outage queue log",
        "backup card-processing method"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "billing",
        "front-desk",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the vendor's public status page or support line to confirm the outage is on their end rather than the practice's own network or internet connection.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the outage is on the vendor's side"
        },
        {
          "detail": "Which service is affected?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "claims",
              "label": "E-claims / clearinghouse"
            },
            {
              "goto": "s9",
              "id": "rx",
              "label": "E-prescribing"
            },
            {
              "goto": "s10",
              "id": "messaging",
              "label": "Patient messaging platform"
            },
            {
              "goto": "s11",
              "id": "card",
              "label": "Card/payment processor"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Which service is affected?"
        },
        {
          "detail": "Continue preparing claims as normal but hold submission; log each held claim with its ready date so none are forgotten once the clearinghouse is back.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Hold claim submission and queue for resubmission"
        },
        {
          "detail": "Check the vendor's status page or support line every 20 minutes until service is confirmed restored.",
          "id": "s4",
          "kind": "timer",
          "role": "it-vendor",
          "timer_seconds": 1200,
          "title": "Monitor the vendor status page for restoration"
        },
        {
          "detail": "Has the vendor confirmed restoration?",
          "forks": [
            {
              "goto": "s4",
              "id": "no",
              "label": "Still down"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "Vendor confirms restored"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Has the vendor confirmed restoration?"
        },
        {
          "detail": "Submit all held claims, e-prescriptions, or messages from the outage window, checking each against the queue log so nothing is missed or duplicated.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Clear the queued items"
        },
        {
          "detail": "Record the vendor, service affected, outage start/end time, workaround used, and queue-clear confirmation.\n\nRecord: Vendor outage log (vendor, service, start/end time, workaround, queue cleared)",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the vendor outage"
        },
        {
          "detail": "Vendor outage resolved and queue cleared",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Vendor outage resolved and queue cleared"
        },
        {
          "detail": "Use the practice's paper or verbal prescribing fallback per clinical policy for anything that cannot wait; queue non-urgent prescriptions for e-prescribing once restored.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Switch to the paper/phone prescribing fallback"
        },
        {
          "detail": "Call patients directly for any message that cannot wait (appointment reminders, urgent follow-up) rather than re-routing PHI-bearing messages through an unapproved channel such as personal text or email.\n\nWhy: An outage is not a reason to move patient communication onto a channel that was never approved for it; the phone is the fallback that stays inside the practice's existing consent and security model.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Fall back to phone contact for time-sensitive patient messages",
          "why": "An outage is not a reason to move patient communication onto a channel that was never approved for it; the phone is the fallback that stays inside the practice's existing consent and security model."
        },
        {
          "detail": "Use the offline terminal or manual imprint/authorization method for payment collection; hold receipts for reconciliation once the primary processor returns.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Switch to the backup card-processing method"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Cloud vendor, clearinghouse or payment-processor outage — A critical third-party service (e-claims, e-prescribing, patient messaging, card terminal) reports an outage.",
      "title": "Cloud vendor, clearinghouse or payment-processor outage",
      "trigger": "A critical third-party service (e-claims, e-prescribing, patient messaging, card terminal) reports an outage",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.316 (contingency plan, access management)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "CISA account-hijacking / credential-compromise guidance - public domain",
          "source": "CISA account-hijacking / credential-compromise guidance - public domain",
          "url": "https://www.cisa.gov/topics/cyber-threats-and-advisories"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "itd-019",
      "kind": "operational",
      "materials": [
        "website hosting/CMS admin login",
        "social media platform admin login",
        "clean website backup",
        "incident log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "it-vendor",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the website or social account shows content the team did not post, and capture a screenshot before touching anything, for the incident record.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Confirm the compromise and screenshot the evidence"
        },
        {
          "detail": "Reset the password on the compromised account, revoke any active sessions or connected apps, and enable MFA if it was not already active.\n\nWhy: A hijacked account often keeps a session token alive even after the visible password is changed; revoking sessions closes that gap.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Lock down access immediately",
          "why": "A hijacked account often keeps a session token alive even after the visible password is changed; revoking sessions closes that gap."
        },
        {
          "detail": "Is this the website (self-hosted/CMS) or a third-party social platform?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "website",
              "label": "Practice website / CMS"
            },
            {
              "goto": "s9",
              "id": "social",
              "label": "Third-party social media account"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Is this the website (self-hosted/CMS) or a third-party social platform?"
        },
        {
          "detail": "If the defacement is severe, temporarily take the site offline or show a maintenance page; restore content from the most recent clean backup and check for any injected code or unauthorized admin account before bringing it back live.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Take the site offline or restore from a clean backup"
        },
        {
          "detail": "Confirm no unauthorized admin users, connected apps, or forwarding rules were added; check whether the same password was reused on any other practice account and rotate it there too.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Check for persistence and other compromised accounts"
        },
        {
          "detail": "Did the hijack post anything that could mislead or alarm patients (e.g. false closure notice, fraudulent offer)?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no",
              "label": "No patient-facing false claim was posted"
            },
            {
              "goto": "s10",
              "id": "yes",
              "label": "A misleading or fraudulent post reached patients"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "marketing",
          "title": "Did the hijack post anything that could mislead or alarm patients (e.g. false closure notice, fraudulent offer)?"
        },
        {
          "detail": "Record what was compromised, how it was discovered, containment actions, whether a public correction was needed, and total time to resolution.\n\nRecord: Website/social account hijack incident log",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Account secured and content restored",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Account secured and content restored"
        },
        {
          "detail": "Delete or hide the unauthorized posts, and use the platform's account-compromise reporting flow to flag the takeover, since some actions (like removing an added admin) may need platform-side support.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Remove unauthorized posts and report the compromise to the platform"
        },
        {
          "detail": "Once the account is confirmed secure, post a short correction clarifying the earlier post was not from the practice, without over-explaining the technical incident.",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Post a brief correction from the restored, verified account"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Website defaced or social-media account hijacked — The practice website shows foreign content, or posts appear on a social account that the team did not write.",
      "title": "Website defaced or social-media account hijacked",
      "trigger": "The practice website shows foreign content, or posts appear on a social account that the team did not write",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.312 (workforce security, access management, device and media controls, transmission security)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.312 (workforce security, access management, device and media controls, transmission security)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-46 Rev.2 Guide to Enterprise Telework, Remote Access, and BYOD Security - public domain",
          "source": "NIST SP 800-46 Rev.2 Guide to Enterprise Telework, Remote Access, and BYOD Security - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/46/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "itd-020",
      "kind": "operational",
      "materials": [
        "remote work agreement form",
        "home-office security checklist",
        "VPN or secure remote-access credentials",
        "timekeeping system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "it-vendor",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the approved remote role (billing, phone/scheduling) does not require in-person patient contact or on-site equipment, and confirm HR has the arrangement documented.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the role and duties are appropriate for remote work"
        },
        {
          "detail": "The agreement covers acceptable use, prohibition on printing or locally saving patient data, screen-privacy expectations, and the practice's right to audit compliance.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Have the team member sign the remote work agreement"
        },
        {
          "detail": "Confirm: (1) the home WiFi network uses WPA2/WPA3 with a strong password, not a default router password, (2) the work device is practice-issued or meets the practice's BYOD security standard, (3) the workstation screen is not visible to other household members or through a window, (4) no local printing or saving of patient data, (5) the device auto-locks after a short idle period.\n\nWhy: A home network is outside the practice's physical and network controls; the checklist rebuilds the equivalent protections item by item rather than assuming they exist.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Walk through the home-office security checklist with the team member",
          "why": "A home network is outside the practice's physical and network controls; the checklist rebuilds the equivalent protections item by item rather than assuming they exist."
        },
        {
          "detail": "Set up VPN or secure remote-desktop access with MFA required; do not allow direct exposure of the practice management system to the open internet.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Configure secure remote access"
        },
        {
          "detail": "Configure the timekeeping system's remote clock-in/out method (app-based or system-based) so hours are tracked the same way as on-site staff.\n\nWhy: Remote arrangements without a matching timekeeping setup are a common generic office-management gap this protocol closes for a role that has no physical time clock to use.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Set up timekeeping for the remote arrangement",
          "why": "Remote arrangements without a matching timekeeping setup are a common generic office-management gap this protocol closes for a role that has no physical time clock to use."
        },
        {
          "detail": "The compliance officer reviews the completed checklist and signed agreement, and confirms sign-off before the team member's account is enabled for remote access to any system containing patient records.\n\nWhy: Remote access to patient-record systems is exactly the kind of access-expansion decision that should never be made unilaterally by IT convenience alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer signs off before remote access to PHI-bearing systems is enabled.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer signs off before remote access to PHI-bearing systems is enabled",
          "why": "Remote access to patient-record systems is exactly the kind of access-expansion decision that should never be made unilaterally by IT convenience alone."
        },
        {
          "detail": "Record the team member's name, role, checklist results, agreement signature date, remote-access method, and sign-off date.\n\nRecord: Remote work setup log (name, role, checklist result, agreement date, access method, sign-off)",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the remote work setup"
        },
        {
          "detail": "Remote work setup complete",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Remote work setup complete"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Remote team member home-office PHI controls and timekeeping setup — A biller or phone team member is approved to work from home.",
      "title": "Remote team member home-office PHI controls and timekeeping setup",
      "trigger": "A biller or phone team member is approved to work from home",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308-164.312 (workforce security, access management, audit controls)",
          "source": "HIPAA Security Rule 45 CFR 164.308-164.312 (workforce security, access management, audit controls)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "itd-021",
      "kind": "operational",
      "materials": [
        "approved remote-support tool",
        "vendor support session log",
        "screen-share privacy checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the request is from a known, expected vendor contact (not an unsolicited caller claiming to be support) and confirm what specific problem the session is meant to fix.\n\nWhy: Unsolicited 'tech support' remote-access requests are a well-known social-engineering pattern; confirming identity and purpose first closes that door.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Confirm the vendor's identity and the reason for the session",
          "why": "Unsolicited 'tech support' remote-access requests are a well-known social-engineering pattern; confirming identity and purpose first closes that door."
        },
        {
          "detail": "Initiate the session through the practice's approved remote-support tool rather than a link or tool the vendor sends unsolicited; decline any request to install a new remote-access tool without the office manager's prior approval.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Use the approved remote-support tool only"
        },
        {
          "detail": "A staff member stays at the workstation for the duration of the session, able to see what the technician is doing and to end the session at any time.\n\nWhy: An unattended remote session removes the practice's ability to know what was actually done or seen; presence is the simplest control that closes that gap.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Have a staff member present for the full session",
          "why": "An unattended remote session removes the practice's ability to know what was actually done or seen; presence is the simplest control that closes that gap."
        },
        {
          "detail": "Close or minimize any window showing patient records that is not directly needed for the fix; if the software issue requires a patient record to be visible to diagnose, keep only the minimum needed on screen for the shortest time necessary.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Minimize PHI exposure before and during the session"
        },
        {
          "detail": "Close the remote-support session at the end of the fix and confirm the tool shows no active or lingering connection; uninstall any temporary remote-access component the vendor's tool left behind.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "End the session and confirm the connection is closed"
        },
        {
          "detail": "Record the vendor, reason for the session, start/end time, staff present, and whether any patient record was visible during the session.\n\nRecord: Vendor remote-support session log (vendor, reason, start/end time, staff present, PHI visible Y/N)",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the vendor session"
        },
        {
          "detail": "Vendor session closed and logged",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Vendor session closed and logged"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Vendor remote-support session controls (screen share, PHI exposure, session log) — A software or imaging vendor asks to remote into a workstation to fix a problem.",
      "title": "Vendor remote-support session controls (screen share, PHI exposure, session log)",
      "trigger": "A software or imaging vendor asks to remote into a workstation to fix a problem",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.312 (access control, audit controls, person or entity authentication)",
          "source": "HIPAA Security Rule 45 CFR 164.312 (access control, audit controls, person or entity authentication)",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR 164.514(h) - verification of identity before disclosure",
          "source": "HIPAA Privacy Rule 45 CFR 164.514(h) - verification of identity before disclosure",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-E"
        },
        {
          "kind": "regulation",
          "label": "HHS Breach Notification Rule 45 CFR 164.400-414",
          "source": "HHS Breach Notification Rule 45 CFR 164.400-414",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-D"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "itd-022",
      "kind": "operational",
      "materials": [
        "patient identity verification checklist",
        "patient portal admin console",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Is this a routine password reset request, or a report that the patient did not send messages showing in their account?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "reset",
              "label": "Routine password reset request"
            },
            {
              "goto": "s6",
              "id": "takeover",
              "label": "Patient reports activity they did not perform"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this a routine password reset request, or a report that the patient did not send messages showing in their account?"
        },
        {
          "detail": "Confirm identity using at least two verification points (full name, date of birth, and one more: address or last visit date) before initiating any password reset; never reset based on the phone number displayed on caller ID alone.\n\nWhy: A portal account is a direct window onto patient records; skipping verification here is exactly how an impersonator gains account access.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Verify the caller's identity before any reset.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "front-desk",
          "title": "Verify the caller's identity before any reset",
          "why": "A portal account is a direct window onto patient records; skipping verification here is exactly how an impersonator gains account access."
        },
        {
          "detail": "Trigger the reset so the patient sets a new password themselves through the portal's normal reset flow (email or SMS to the address/number on file) rather than the staff choosing or reading back a password.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Reset the password through the portal admin console"
        },
        {
          "detail": "Record the patient, verification method used, and reset date.\n\nRecord: Portal reset log (patient, verification method, date)",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the reset"
        },
        {
          "detail": "Portal account matter resolved",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Portal account matter resolved"
        },
        {
          "detail": "Immediately disable login on the account, and review the account's login history and message log for the period the patient did not recognize.\n\nWhy: Locking first prevents any further unauthorized activity while the review happens, rather than leaving a compromised account open during investigation.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Lock the account and review activity",
          "why": "Locking first prevents any further unauthorized activity while the review happens, rather than leaving a compromised account open during investigation."
        },
        {
          "detail": "Call the patient back at the phone number on file (not a number provided in the report itself) to confirm the report and verify identity before making any account change.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify the patient's identity through an independent channel"
        },
        {
          "detail": "Because the portal account holds patient records and the activity is unexplained, the compliance officer opens a formal breach risk assessment per the HIPAA breach-analysis protocol before any public statement or resolution is finalized.\n\nWhy: Whether unauthorized portal access is a reportable event is a compliance determination with regulatory consequences, not something front desk or IT resolves on their own.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer opens the breach risk assessment.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer opens the breach risk assessment",
          "why": "Whether unauthorized portal access is a reportable event is a compliance determination with regulatory consequences, not something front desk or IT resolves on their own."
        },
        {
          "detail": "Once identity is confirmed and the assessment is underway, reset the account with a new password delivered through the patient's verified channel.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Reissue access to the verified patient"
        },
        {
          "detail": "Record the report details, containment actions, verification outcome, and whether a breach assessment was opened.\n\nRecord: Patient portal suspected takeover incident log",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the suspected takeover incident"
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Patient portal account access request or suspected account takeover — A caller asks for a portal password reset, or a patient reports messages they did not send.",
      "title": "Patient portal account access request or suspected account takeover",
      "trigger": "A caller asks for a portal password reset, or a patient reports messages they did not send",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164.308(a)(1) - risk analysis and risk management",
          "source": "HIPAA Security Rule 45 CFR 164.308(a)(1) - risk analysis and risk management",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "public_domain",
          "label": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "source": "NIST SP 800-66 Rev.2 (HIPAA Security Rule implementation guide) - public domain",
          "url": "https://csrc.nist.gov/pubs/sp/800/66/r2/final"
        },
        {
          "kind": "public_domain",
          "label": "CISA / HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "source": "CISA / HHS 405(d) Health Industry Cybersecurity Practices - public domain",
          "url": "https://405d.hhs.gov/"
        }
      ],
      "class": "practice-assets-and-it",
      "department": "it",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "itd-023",
      "kind": "operational",
      "materials": [
        "hardware and software asset inventory",
        "vendor end-of-life/end-of-support notice",
        "compensating-controls checklist",
        "upgrade/replacement budget estimate"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Cross-check the asset inventory against the vendor's published end-of-support notice to confirm exactly which workstation, server or imaging PC is affected and when support ends or has ended.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Identify the system and confirm the end-of-support date"
        },
        {
          "detail": "Does the affected system run or access software containing patient records?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "Yes - the system touches patient-record systems"
            },
            {
              "goto": "s9",
              "id": "no",
              "label": "No - isolated, non-PHI use only"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "it-vendor",
          "title": "Does the affected system run or access software containing patient records?"
        },
        {
          "detail": "Identify whether the fix is an in-place upgrade (new OS version on the same hardware), a hardware replacement, or a vendor-provided extended-support option, and estimate cost and timeline for each.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Determine the remediation path"
        },
        {
          "detail": "Can remediation happen immediately, or is there a gap period first?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "immediate",
              "label": "Remediation can proceed now"
            },
            {
              "goto": "s10",
              "id": "gap",
              "label": "There will be a gap before replacement/upgrade"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Can remediation happen immediately, or is there a gap period first?"
        },
        {
          "detail": "Perform the upgrade, replacement, or extended-support enrollment; confirm the practice management, imaging, or other affected software runs correctly on the remediated system before returning it to production use.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Execute the remediation"
        },
        {
          "detail": "Record the new OS/software version and support end date in the hardware and software asset inventory (itd-016) so the next end-of-life date is tracked going forward.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Update the asset inventory"
        },
        {
          "detail": "Record the system, original end-of-support date, remediation path chosen, compensating controls used if any, and completion date.\n\nRecord: End-of-life remediation log (system, end-of-support date, remediation path, controls, completion date)",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the remediation"
        },
        {
          "detail": "End-of-life system remediated",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "End-of-life system remediated"
        },
        {
          "detail": "Isolate the non-PHI system from the main network where practical, and schedule its upgrade or replacement on the normal hardware refresh cycle.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Isolate and schedule routine replacement"
        },
        {
          "detail": "Isolate the system on its own network segment away from other devices, remove any unnecessary network access (including internet access if the software allows local-only operation), restrict login to the minimum staff who need it, and increase monitoring for unusual activity.\n\nWhy: An unsupported system holding patient records cannot simply wait unmanaged for a budget cycle - compensating controls are what keep the risk documented and contained rather than silently accepted.",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Put compensating controls in place for the gap period",
          "why": "An unsupported system holding patient records cannot simply wait unmanaged for a budget cycle - compensating controls are what keep the risk documented and contained rather than silently accepted."
        },
        {
          "detail": "The compliance officer reviews the compensating controls and the planned remediation timeline, and signs off that the interim risk is documented and acceptable until replacement, rather than the gap going unrecorded.\n\nWhy: Accepting a known security gap without a named sign-off and a deadline is how a 'temporary' unsupported system quietly becomes permanent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer signs off on the interim risk acceptance.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer signs off on the interim risk acceptance",
          "why": "Accepting a known security gap without a named sign-off and a deadline is how a 'temporary' unsupported system quietly becomes permanent."
        }
      ],
      "subclass": "it-operations-and-security-incidents",
      "summary": "Unsupported operating system or end-of-life software remediation — A workstation, server or imaging PC reaches vendor end-of-support.",
      "title": "Unsupported operating system or end-of-life software remediation",
      "trigger": "A workstation, server or imaging PC reaches vendor end-of-support",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)",
          "source": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "ivb-001",
      "kind": "operational",
      "materials": [
        "intake form (paper or online)",
        "insurance card image capture",
        "practice management system record"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Collect subscriber name, date of birth, relationship to patient, insurer name, member ID, and group number by phone or via the online intake form.\n\nWhy: Accurate subscriber identifiers are required before any electronic eligibility check can run.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive insurance information from the new patient",
          "why": "Accurate subscriber identifiers are required before any electronic eligibility check can run."
        },
        {
          "detail": "Ask the patient to photograph or upload both sides of the card, or scan it at check-in if intake is completed in person.\n\nWhy: The card carries the payer ID and claims address needed for electronic transactions and often catches typos in the verbal member ID.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Capture insurance card images (front and back)",
          "why": "The card carries the payer ID and claims address needed for electronic transactions and often catches typos in the verbal member ID."
        },
        {
          "detail": "Confirm subscriber name, DOB, insurer, and member ID or group number are all present.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "complete",
              "label": "All required fields present"
            },
            {
              "goto": "s8",
              "id": "incomplete",
              "label": "A required field is missing"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Is the intake complete enough to run eligibility?"
        },
        {
          "detail": "Create or update the patient's insurance profile with subscriber, insurer, member ID, group number, and card images attached.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Enter insurance record into the practice management system"
        },
        {
          "detail": "Mark the new patient's record as pending eligibility so it is picked up automatically two business days before the visit.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Flag the appointment for pre-visit eligibility batch"
        },
        {
          "detail": "Log the date intake was completed and by whom in the patient's insurance record.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record intake completion"
        },
        {
          "detail": "Intake complete",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Intake complete"
        },
        {
          "detail": "Call or message the patient asking specifically for the missing field (e.g. member ID) before the appointment.\n\nWhy: Running eligibility on an incomplete record produces an unreliable response and wastes the batch check.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Request the missing information from the patient",
          "why": "Running eligibility on an incomplete record produces an unreliable response and wastes the batch check."
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "New patient insurance intake at booking — A new patient provides insurance information by phone or online form.",
      "title": "New patient insurance intake at booking",
      "trigger": "A new patient provides insurance information by phone or online form",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 60,
      "frequency": "daily",
      "id": "ivb-002",
      "kind": "operational",
      "materials": [
        "electronic eligibility (270/271) tool",
        "practice schedule report",
        "phone verification worksheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Export or view the list of all patients scheduled for the date two business days from today.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Pull the schedule for the target date (two business days out)"
        },
        {
          "detail": "Submit each scheduled patient's insurance record through the electronic eligibility tool and collect the 271 responses.\n\nWhy: Batch electronic checks are far faster than individual phone calls and surface most coverage issues automatically.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Run the electronic eligibility (270/271) batch",
          "why": "Batch electronic checks are far faster than individual phone calls and surface most coverage issues automatically."
        },
        {
          "detail": "Check each response for active coverage, matching plan on file, and no error/timeout.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean",
              "label": "Active, matches record, no errors"
            },
            {
              "goto": "s8",
              "id": "exception",
              "label": "Inactive, mismatched, or no response"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Did the electronic response come back clean?"
        },
        {
          "detail": "Record the verification date, plan status, and any relevant benefit flags in the patient's chart.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Mark the patient as eligibility-verified"
        },
        {
          "detail": "For each exception: call the payer or use the payer portal, confirm active coverage and plan details, update the record, and note who was spoken to.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Work the exception list by phone"
        },
        {
          "detail": "Any patient whose coverage could not be confirmed is flagged for front desk to call before the appointment.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand unresolved exceptions to front desk for patient outreach"
        },
        {
          "detail": "Batch complete",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Batch complete"
        },
        {
          "detail": "Add the patient to today's exception worklist noting the reason (inactive, mismatch, no response, timeout).",
          "id": "s8",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Log the exception for phone follow-up"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Pre-visit eligibility verification batch (two business days out) — Daily — every appointment two business days out is checked electronically and exceptions are worked by phone.",
      "title": "Pre-visit eligibility verification batch (two business days out)",
      "trigger": "Daily — every appointment two business days out is checked electronically and exceptions are worked by phone",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "ivb-003",
      "kind": "operational",
      "materials": [
        "270/271 eligibility response",
        "payer portal or phone",
        "benefits breakdown worksheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm whether the trigger is a brand-new plan on file or the calendar/plan-year rollover for an existing patient.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Identify the plan needing a full breakdown"
        },
        {
          "detail": "Run or review the most recent electronic eligibility response for the plan to get the baseline active/inactive status and any included benefit detail.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Pull the current 270/271 eligibility response"
        },
        {
          "detail": "Record, by category (diagnostic/preventive, basic restorative, major restorative, endodontics, periodontics, prosthodontics, oral surgery, orthodontics as applicable): coverage percentage, annual maximum, deductible, waiting periods, and frequency limits.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Gather benefit detail by category"
        },
        {
          "detail": "Some payers return full category-level detail electronically; others require a call to a benefits line.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "electronic-sufficient",
              "label": "Electronic response has full category detail"
            },
            {
              "goto": "s8",
              "id": "call-needed",
              "label": "Category detail missing — call the payer"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Was the electronic response detailed enough, or is a phone call needed?"
        },
        {
          "detail": "Save category-level coverage percentages, maximums, deductibles, waiting periods, and frequency limits to the patient's insurance profile.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Enter the full breakdown into the practice management system"
        },
        {
          "detail": "Note whether the breakdown came from electronic response or phone call, who verified it, and the date, so staleness can be tracked.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the source and date of the breakdown"
        },
        {
          "detail": "Breakdown on file",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Breakdown on file"
        },
        {
          "detail": "Contact the payer's provider/benefits line, verify caller identity per payer script, and record the missing coverage percentages and limits.\n\nWhy: Not every payer's electronic transaction returns full benefit detail — some require a supplemental call to get complete category breakdowns.",
          "id": "s8",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Call the payer to fill in missing categories",
          "why": "Not every payer's electronic transaction returns full benefit detail — some require a supplemental call to get complete category breakdowns."
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Full benefits breakdown entry (new plan or annual reset) — A new plan is put on file or the plan year rolls over.",
      "title": "Full benefits breakdown entry (new plan or annual reset)",
      "trigger": "A new plan is put on file or the plan year rolls over",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "ivb-004",
      "kind": "operational",
      "materials": [
        "benefits breakdown on file",
        "treatment history in practice management system",
        "payer frequency table"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note the CDT-type service (e.g. exam, cleaning, bitewings, crown, ortho) and whether the plan on file has a frequency, waiting-period, or age limit for it.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Identify the service being scheduled and its frequency rule category"
        },
        {
          "detail": "Look up the last date this or a related service was performed and compare against the plan's stated frequency (e.g. two cleanings per calendar year, one bitewing series per 6 months).",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Check the patient's treatment history for the last date of service"
        },
        {
          "detail": "Compare the last-service date and any waiting period or age limit against the plan's rule.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "within",
              "label": "Within limits — proceed as scheduled"
            },
            {
              "goto": "s7",
              "id": "exceeds",
              "label": "Exceeds frequency, waiting period, or age limit"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Is the requested service within the plan's frequency/limitation rules?"
        },
        {
          "detail": "No limitation issue found; proceed with normal scheduling.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Confirm the appointment as scheduled"
        },
        {
          "detail": "Note in the appointment or patient record that a frequency/limitation check was performed, the result, and whether the patient was notified.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the frequency check outcome"
        },
        {
          "detail": "Check complete",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Check complete"
        },
        {
          "detail": "Explain in plain terms that the plan will not cover the service at this time (or will apply a waiting period), and note the expected patient portion if they choose to proceed anyway.\n\nWhy: Surfacing the limitation before the visit avoids a surprise bill and gives the patient a chance to reschedule or accept the cost.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Notify the patient of the limitation before the visit",
          "why": "Surfacing the limitation before the visit avoids a surprise bill and gives the patient a chance to reschedule or accept the cost."
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Frequency, waiting-period and limitation check before scheduling — A service with frequency limits, waiting periods or age limits is being scheduled.",
      "title": "Frequency, waiting-period and limitation check before scheduling",
      "trigger": "A service with frequency limits, waiting periods or age limits is being scheduled",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Penal Code §632 when verification calls are recorded",
          "source": "California Penal Code §632 when verification calls are recorded"
        },
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "ivb-005",
      "kind": "operational",
      "materials": [
        "payer phone number / provider line",
        "verification call script",
        "insurance card image"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "If the practice records verification calls, confirm two-party consent is disclosed at the start of the call per California Penal Code §632 before any recording begins; if consent cannot be given or the call is not being recorded, proceed without recording.\n\nWhy: Recording a phone call without required consent is a criminal exposure under §632 — the gate exists to make consent a decision point, not an assumption.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm call-recording consent status before recording.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "insurance-coordinator",
          "title": "Confirm call-recording consent status before recording",
          "why": "Recording a phone call without required consent is a criminal exposure under §632 — the gate exists to make consent a decision point, not an assumption."
        },
        {
          "detail": "Have subscriber name, DOB, member ID, group number, and the insurance card image ready.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Gather subscriber and plan information before dialing"
        },
        {
          "detail": "Dial the number on the insurance card or provider portal, navigate to the eligibility/benefits department, and authenticate as the provider's office.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Call the payer's provider/benefits line"
        },
        {
          "detail": "Note the payer representative's name/ID and the call reference number provided.\n\nWhy: A reference number is the practice's evidence of what was verbally verified if a later claim is denied contrary to what was told.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Verify representative and record reference number",
          "why": "A reference number is the practice's evidence of what was verbally verified if a later claim is denied contrary to what was told."
        },
        {
          "detail": "Confirm plan is active, subscriber matches, and benefit levels are as expected.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "confirmed",
              "label": "Coverage confirmed and matches"
            },
            {
              "goto": "s9",
              "id": "unresolved",
              "label": "Still inactive, mismatched, or unclear"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Was active, matching coverage confirmed?"
        },
        {
          "detail": "Enter confirmed plan status, benefit levels, and the call reference number into the practice management system.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Update the patient's insurance record with verified detail"
        },
        {
          "detail": "Document date, representative name/ID, reference number, and verified details (or escalation reason) in the patient's record.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the call outcome"
        },
        {
          "detail": "Phone verification complete",
          "id": "s8",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Phone verification complete"
        },
        {
          "detail": "Hand the case to front desk to contact the patient directly for updated insurance information or a supervisor for further payer escalation.",
          "id": "s9",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Escalate to front desk / patient for clarification"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Insurance verification by phone when electronic eligibility fails — Electronic eligibility is unavailable or ambiguous for a scheduled patient.",
      "title": "Insurance verification by phone when electronic eligibility fails",
      "trigger": "Electronic eligibility is unavailable or ambiguous for a scheduled patient",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)",
          "source": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "ivb-006",
      "kind": "operational",
      "materials": [
        "both insurance cards",
        "COB worksheet",
        "practice management system record"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm both plans' subscriber names, relationship to the patient (self, spouse, parent), and card images are on file.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify both insurance plans on file"
        },
        {
          "detail": "For a dependent child with two parent plans, apply the birthday rule (the subscriber whose birth month/day falls earlier in the calendar year is primary). For a patient covered as subscriber on one plan and dependent on another, the plan where the patient is the subscriber is primary. Court-ordered coverage order overrides the birthday rule where documented.\n\nWhy: Coordination-of-benefits rules determine which payer is billed first — billing them out of order routinely causes denials and rework.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "birthday-rule",
              "label": "Birthday rule applies (dependent child, both parents cover)"
            },
            {
              "goto": "s3",
              "id": "subscriber-rule",
              "label": "Patient is subscriber on one plan — that plan is primary"
            },
            {
              "goto": "s7",
              "id": "unclear",
              "label": "Order is unclear or disputed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Which plan is primary?",
          "why": "Coordination-of-benefits rules determine which payer is billed first — billing them out of order routinely causes denials and rework."
        },
        {
          "detail": "Enter which plan is primary and which is secondary in the patient's insurance profile, with the basis for the determination noted.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record primary and secondary plan designation"
        },
        {
          "detail": "Confirm active status and benefit levels for both the primary and secondary plan so secondary coordination (non-duplication vs. standard COB) can be applied correctly at claim time.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Verify benefits on both plans"
        },
        {
          "detail": "Document the primary/secondary order, basis, and both plans' verified benefit levels in the patient's chart.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the COB determination"
        },
        {
          "detail": "COB determination complete",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "COB determination complete"
        },
        {
          "detail": "Contact each payer's benefits line, describe the household coverage situation, and ask each payer to confirm whether they consider themselves primary or secondary.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Call both payers to confirm coordination order"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Coordination of benefits (dual coverage) — A patient has two plans — primary determined by the birthday rule or plan rules, both recorded.",
      "title": "Coordination of benefits (dual coverage)",
      "trigger": "A patient has two plans — primary determined by the birthday rule or plan rules, both recorded",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)",
          "source": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "ivb-007",
      "kind": "operational",
      "materials": [
        "eligibility response showing the discrepancy",
        "patient contact information",
        "financial policy / self-pay disclosure form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Re-check the eligibility response against the plan on file to rule out a data-entry error before treating it as a real plan change.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm the discrepancy between eligibility response and record on file"
        },
        {
          "detail": "Call, text, or message the patient asking whether their coverage has changed and requesting current insurance details.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the patient for updated insurance information"
        },
        {
          "detail": "Determine whether the patient supplied a new active plan, confirmed they now have no coverage, or did not respond before the appointment.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "new-plan",
              "label": "Patient provided a new active plan"
            },
            {
              "goto": "s7",
              "id": "no-coverage",
              "label": "Patient confirms no current coverage"
            },
            {
              "goto": "s7",
              "id": "no-response",
              "label": "No response before the appointment"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Did the patient provide updated, valid coverage?"
        },
        {
          "detail": "Run the new plan through electronic eligibility, or call the payer if unavailable, and update the benefits breakdown.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Verify the new plan electronically or by phone"
        },
        {
          "detail": "Document what was found, how it was resolved (new plan verified, self-pay disclosed, or appointment rescheduled), and the date.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the resolution"
        },
        {
          "detail": "Discrepancy resolved",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Discrepancy resolved"
        },
        {
          "detail": "Have the office manager or treatment coordinator confirm the self-pay financial policy and estimated cost will be disclosed to the patient before the appointment proceeds without confirmed coverage.\n\nWhy: Proceeding on an unconfirmed self-pay basis has real financial consequences for the patient and the practice — a second set of eyes catches missed coverage before the patient is billed in full.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor sign-off before treating the visit as self-pay.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor sign-off before treating the visit as self-pay",
          "why": "Proceeding on an unconfirmed self-pay basis has real financial consequences for the patient and the practice — a second set of eyes catches missed coverage before the patient is billed in full."
        },
        {
          "detail": "Inform the patient in plain language that no active coverage was confirmed, provide an estimated cost, and obtain their acknowledgment before the visit.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Disclose self-pay status and estimated cost to the patient"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Plan change or termination discovered at verification — Eligibility returns inactive or a different plan than on file for an upcoming appointment.",
      "title": "Plan change or termination discovered at verification",
      "trigger": "Eligibility returns inactive or a different plan than on file for an upcoming appointment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271 and prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)",
          "source": "State prompt-pay and assignment-of-benefits statutes (varies; CA Ins. Code §10123.13, H&S §1371)"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "ivb-008",
      "kind": "operational",
      "materials": [
        "out-of-network benefits verification",
        "fee schedule (practice's own fees)",
        "written estimate / disclosure form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "treatment-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the payer's provider directory or contract list to confirm the practice is not a contracted/in-network provider for this plan.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm the plan is out-of-network for this practice"
        },
        {
          "detail": "Call the payer or check electronic eligibility for the plan's out-of-network coverage percentage, deductible, and any usual-and-customary or allowed-amount basis used for reimbursement.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Verify out-of-network benefit levels"
        },
        {
          "detail": "Apply the verified out-of-network benefit percentage against the practice's own fees (not the payer's in-network fee schedule) to estimate patient responsibility.\n\nWhy: An out-of-network estimate must be based on what the practice actually charges — using an in-network fee schedule the patient's plan doesn't apply here understates their true cost.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Build a written cost estimate using the practice's fee schedule",
          "why": "An out-of-network estimate must be based on what the practice actually charges — using an in-network fee schedule the patient's plan doesn't apply here understates their true cost."
        },
        {
          "detail": "Walk the patient through the estimate, explain that reimbursement is not guaranteed and may be paid to the patient rather than the practice depending on the plan, and provide a written copy.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the estimate to the patient in writing"
        },
        {
          "detail": "Confirm the patient understands the estimate and payment responsibility before scheduling treatment.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "proceed",
              "label": "Patient acknowledges and proceeds"
            },
            {
              "goto": "s6",
              "id": "decline",
              "label": "Patient wants to reconsider or seek in-network options"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient wish to proceed?"
        },
        {
          "detail": "Document the estimate provided, date, and whether the patient chose to proceed, decline, or seek further information.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the disclosure and patient response"
        },
        {
          "detail": "Out-of-network disclosure complete",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Out-of-network disclosure complete"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Out-of-network benefit estimate and patient disclosure — A patient's plan does not contract with the practice.",
      "title": "Out-of-network benefit estimate and patient disclosure",
      "trigger": "A patient's plan does not contract with the practice",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "regulation",
          "label": "Medicaid provider requirements 42 CFR Part 455",
          "source": "Medicaid provider requirements 42 CFR Part 455",
          "url": "https://www.ecfr.gov/current/title-42/part-455"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "ivb-009",
      "kind": "operational",
      "materials": [
        "state eligibility verification portal login",
        "patient program card or case/member number",
        "practice payer enrollment roster",
        "benefit breakdown worksheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm from the intake information or ID card whether the patient's coverage is a state Medicaid dental benefit, CHIP dental benefit, or another state public dental program, and note the exact program name and case/member ID field.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Identify the state public dental program"
        },
        {
          "detail": "Look up the patient's eligibility on the state's eligibility verification portal, or via a 270/271 eligibility transaction, to confirm the program shows active coverage as of the appointment date.\n\nWhy: State program eligibility can change monthly; a stale card is one of the most common reasons a claim is denied.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Check the patient's current enrollment status",
          "why": "State program eligibility can change monthly; a stale card is one of the most common reasons a claim is denied."
        },
        {
          "detail": "Is the patient shown active on the state program?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "active",
              "label": "Portal or 270/271 shows active coverage"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "inactive",
              "label": "Portal shows inactive, pending, or no record found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Is the patient shown active on the state program?"
        },
        {
          "detail": "Check the office's payer enrollment roster to confirm the treating dentist is currently enrolled and in good standing with this exact state program; many state programs pay only enrolled providers. Also confirm the treating dentist has a current federal exclusion screen on file (OIG List of Excluded Individuals/Entities and SAM.gov) and is not excluded.\n\nWhy: An unenrolled provider's claims are denied outright regardless of the patient's own eligibility.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm the practice is enrolled with this specific state program",
          "why": "An unenrolled provider's claims are denied outright regardless of the patient's own eligibility."
        },
        {
          "detail": "Is the treating dentist enrolled with this program?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "enrolled",
              "label": "Enrolled and in good standing"
            },
            {
              "advised": false,
              "goto": "s15",
              "id": "not-enrolled",
              "label": "Not enrolled or enrollment lapsed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Is the treating dentist enrolled with this program?"
        },
        {
          "detail": "Confirm: covered CDT procedure codes and any exclusions; annual or lifetime service limits and frequency rules; copay or coinsurance by service category; whether the program requires prior authorization for the planned procedure.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Pull the covered-service list, limits, and cost-share amounts"
        },
        {
          "detail": "Does the planned service require prior authorization under this program?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "required",
              "label": "Program requires prior authorization for this service"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "not-required",
              "label": "Program confirms no prior authorization needed"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does the planned service require prior authorization under this program?"
        },
        {
          "detail": "Note in the patient's account that this service requires prior authorization under the state program, and route the case to the prior authorization submission and tracking protocol before the appointment is confirmed.",
          "id": "s8",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Flag the case for prior authorization"
        },
        {
          "detail": "Enter covered services, limits, cost-share amounts, and authorization status into the patient's benefits record so front desk and the treatment coordinator can quote accurately at check-in.\n\nRecord: benefit breakdown fields in the patient insurance record",
          "id": "s9",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Document the full benefit breakdown"
        },
        {
          "detail": "Send the scheduler and treatment coordinator the verified benefit summary so the appointment can be confirmed with an accurate patient cost estimate.",
          "id": "s10",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand off the confirmed benefits to the scheduler"
        },
        {
          "detail": "State program verification complete",
          "id": "s11",
          "kind": "step",
          "title": "State program verification complete"
        },
        {
          "detail": "Record the eligibility check date, the result, and the reason code returned (for example disenrolled or pending redetermination) in the patient's account notes.\n\nRecord: eligibility check outcome in patient account notes",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Document the inactive eligibility result"
        },
        {
          "detail": "Notify front desk of the coverage gap so they can call the patient, explain the finding, and offer a self-pay estimate or reschedule before the appointment.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to front desk to reach the patient before the visit"
        },
        {
          "detail": "Inactive coverage handled before the visit",
          "id": "s14",
          "kind": "step",
          "title": "Inactive coverage handled before the visit"
        },
        {
          "detail": "Send the office manager the program name, patient, and appointment date so enrollment can be started or an alternate arrangement made before the visit.",
          "id": "s15",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Notify the office manager of an enrollment gap"
        },
        {
          "detail": "Enrollment gap escalated to office manager",
          "id": "s16",
          "kind": "step",
          "title": "Enrollment gap escalated to office manager"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "State Medicaid / public dental program verification and authorization — A patient is covered by a state public dental program.",
      "title": "State Medicaid / public dental program verification and authorization",
      "trigger": "A patient is covered by a state public dental program",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — prior-authorization 278",
          "source": "HIPAA transaction standards 45 CFR Part 162 — prior-authorization 278",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "per-use",
      "id": "ivb-010",
      "kind": "operational",
      "materials": [
        "payer prior-authorization form or portal",
        "diagnostic images and chart notes supporting necessity",
        "prior-authorization tracking log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Flag any planned procedure whose payer requires prior authorization before treatment, based on the benefit breakdown or known payer policy.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Identify a planned service that requires prior authorization"
        },
        {
          "detail": "Pull the diagnostic images, periodontal charting, or clinical narrative needed to support medical or dental necessity for the requested service from the chart.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Gather supporting clinical documentation"
        },
        {
          "detail": "Complete the payer's prior authorization form or 278 transaction with the CDT code(s), tooth or site, diagnosis, and supporting narrative.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Draft the prior authorization request"
        },
        {
          "detail": "The treating dentist reviews the clinical necessity, diagnosis, and requested procedure, and signs the prior authorization request. The request is never submitted without this signature.\n\nWhy: Clinical and billing submissions never auto-submit; a licensed provider must attest to necessity before the request leaves the office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs the request before submission.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs the request before submission",
          "why": "Clinical and billing submissions never auto-submit; a licensed provider must attest to necessity before the request leaves the office."
        },
        {
          "detail": "Submit via the payer's electronic 278 transaction or portal, and record the submission date and confirmation or tracking number.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Submit the request to the payer"
        },
        {
          "detail": "Enter the patient, service, submission date, tracking number, and expected response window into the prior-authorization tracking log.\n\nRecord: prior-authorization tracking log entry",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Log the authorization request in the tracking log"
        },
        {
          "detail": "Allow the payer's stated turnaround window (typically 5 to 14 business days). If there is no response after 7 calendar days, place a follow-up call.",
          "id": "s7",
          "kind": "timer",
          "role": "insurance-coordinator",
          "timer_seconds": 604800,
          "title": "Wait for the payer's response, then follow up if silent"
        },
        {
          "detail": "What did the payer decide?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "approved",
              "label": "Approved"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "denied",
              "label": "Denied"
            },
            {
              "advised": false,
              "goto": "s15",
              "id": "no-response",
              "label": "No response after the follow-up window"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "What did the payer decide?"
        },
        {
          "detail": "Send the scheduler and treatment coordinator the approval number and any authorized service window so the appointment can be confirmed.",
          "id": "s9",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Notify scheduling the case is cleared to proceed"
        },
        {
          "detail": "Prior authorization approved and logged",
          "id": "s10",
          "kind": "step",
          "title": "Prior authorization approved and logged"
        },
        {
          "detail": "Bring the denial letter and reason code to the treating dentist to decide whether to appeal, submit additional documentation, or discuss alternative treatment with the patient.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Review the denial reason with the dentist"
        },
        {
          "detail": "How should the denial be handled?",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "appeal",
              "label": "Appeal with additional documentation"
            },
            {
              "advised": false,
              "goto": "s17",
              "id": "accept",
              "label": "Accept the denial and discuss alternatives with the patient"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "dentist",
          "title": "How should the denial be handled?"
        },
        {
          "detail": "Submit a written appeal with additional clinical documentation within the payer's appeal window, and update the tracking log with the appeal date.",
          "id": "s13",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "File a documented appeal"
        },
        {
          "detail": "Appeal filed and tracked",
          "id": "s14",
          "kind": "step",
          "title": "Appeal filed and tracked"
        },
        {
          "detail": "Call the payer's prior-authorization line for a status update on the pending request.",
          "id": "s15",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Escalate the unanswered request"
        },
        {
          "detail": "Determine whether the payer's representative gave a new expected decision date on this first follow-up call, or whether this is already the second unanswered follow-up attempt.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "keep-waiting",
              "label": "Payer gave a new expected date and this is the first follow-up call"
            },
            {
              "advised": false,
              "goto": "s19",
              "id": "stalled",
              "label": "Second follow-up attempt with no resolution"
            }
          ],
          "id": "s16",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Did the follow-up call resolve or explain the silence?"
        },
        {
          "detail": "Inform the treatment coordinator so the patient can be offered alternative treatment options or a self-pay estimate before the visit.",
          "id": "s17",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Notify the patient and treatment coordinator of the denial"
        },
        {
          "detail": "Denial communicated, no appeal filed",
          "id": "s18",
          "kind": "step",
          "title": "Denial communicated, no appeal filed"
        },
        {
          "detail": "Send the office manager the patient, service, submission date, tracking number, and both follow-up call outcomes so they can intervene directly with the payer.",
          "id": "s19",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Escalate the stalled request to the office manager"
        },
        {
          "detail": "Follow-up escalation logged",
          "id": "s20",
          "kind": "step",
          "title": "Follow-up escalation logged"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Prior authorization submission and tracking — A planned service requires payer prior authorization — the dentist signs the request, the coordinator submits and tracks it.",
      "title": "Prior authorization submission and tracking",
      "trigger": "A planned service requires payer prior authorization — the dentist signs the request, the coordinator submits and tracks it",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 835 remittance advice",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 835 remittance advice",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "State prompt-pay and assignment-of-benefits statutes (varies; e.g. California Ins. Code §10123.13, H&S §1371)",
          "source": "State prompt-pay and assignment-of-benefits statutes (varies; e.g. California Ins. Code §10123.13, H&S §1371)"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "ivb-011",
      "kind": "operational",
      "materials": [
        "EOB or 835 remittance",
        "original benefit verification notes",
        "patient estimate on file"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Compare the EOB or 835 remittance payment and patient responsibility against the benefit estimate given to the patient at checkout.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Identify a discrepancy between the quoted estimate and the actual payment"
        },
        {
          "detail": "Calculate the dollar difference between the quoted estimate and the actual adjudicated amount, and note which line items differ.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Quantify the size and direction of the discrepancy"
        },
        {
          "detail": "Is the discrepancy large enough to review before billing the patient?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "review",
              "label": "Discrepancy exceeds the practice's review threshold"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "minor",
              "label": "Small variance within normal rounding or timing"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Is the discrepancy large enough to review before billing the patient?"
        },
        {
          "detail": "Retrieve the eligibility check, benefit breakdown, and any phone verification notes used to build the original patient estimate.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Pull the original eligibility and benefits verification"
        },
        {
          "detail": "Check whether the original verification data — frequency limit, coverage percentage, deductible, waiting period — matches what the payer's EOB actually applied.\n\nWhy: Most estimate-to-EOB gaps trace to a plan detail that changed or was misread, not a payer error.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Compare the verification source to the payer's actual adjudication",
          "why": "Most estimate-to-EOB gaps trace to a plan detail that changed or was misread, not a payer error."
        },
        {
          "detail": "Where is the discrepancy coming from?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "office-error",
              "label": "The original verification missed or misread a plan detail"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "payer-error",
              "label": "The payer's adjudication contradicts its own verified benefits"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Where is the discrepancy coming from?"
        },
        {
          "detail": "Document what was missed, such as a frequency limit or coordination-of-benefits order, correct the patient account, and flag the error type for the quality-review follow-up.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Correct the verification error and update the account"
        },
        {
          "detail": "Send billing the corrected patient responsibility so the account and any patient statement reflect the accurate amount.",
          "id": "s8",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand the corrected figures to billing"
        },
        {
          "detail": "Office-side error corrected and documented",
          "id": "s9",
          "kind": "step",
          "title": "Office-side error corrected and documented"
        },
        {
          "detail": "Post the remittance as received and add a short note to the account explaining the small variance, such as rounding or deductible timing.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Post the payment and note the minor variance"
        },
        {
          "detail": "Minor variance posted, no further review needed",
          "id": "s11",
          "kind": "step",
          "title": "Minor variance posted, no further review needed"
        },
        {
          "detail": "Submit a written inquiry to the payer referencing the original verification reference number, requesting reprocessing since the adjudication contradicts the benefits the payer itself quoted.",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "File a payer inquiry or appeal"
        },
        {
          "detail": "Allow the payer's standard inquiry turnaround, roughly two weeks, and follow up by phone if unresolved.",
          "id": "s13",
          "kind": "timer",
          "role": "insurance-coordinator",
          "timer_seconds": 1209600,
          "title": "Wait for the payer's response to the inquiry"
        },
        {
          "detail": "Inform the patient, via front desk or billing, that the balance is under payer review and hold further collection activity until it is resolved.",
          "id": "s14",
          "kind": "step",
          "role": "billing",
          "title": "Notify the patient the balance is under review"
        },
        {
          "detail": "Payer inquiry filed, balance held pending resolution",
          "id": "s15",
          "kind": "step",
          "title": "Payer inquiry filed, balance held pending resolution"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Verified benefits disagree with the payment or EOB — The estimate given at checkout differs materially from the payer's actual adjudication.",
      "title": "Verified benefits disagree with the payment or EOB",
      "trigger": "The estimate given at checkout differs materially from the payer's actual adjudication",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271",
          "source": "HIPAA transaction standards 45 CFR Part 162 — eligibility 270/271",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "annual",
      "id": "ivb-012",
      "kind": "operational",
      "materials": [
        "card scanner or camera",
        "annual refresh due list",
        "eligibility verification portal"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull all active patients whose plan year resets in January or on their own specific plan renewal date.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Generate the list of active patients needing a new-year refresh"
        },
        {
          "detail": "Front desk asks each patient on the refresh list for their current insurance card, front and back, at check-in or via the online intake portal before the visit.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Request an updated insurance card at check-in"
        },
        {
          "detail": "Was an updated card or plan information provided?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "received",
              "label": "Updated card or plan info provided"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "not-received",
              "label": "Nothing new provided"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was an updated card or plan information provided?"
        },
        {
          "detail": "Scan or photograph the new card and compare payer name, group number, and subscriber ID against what is currently on file.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Scan the card and compare it to the record on file"
        },
        {
          "detail": "Did the payer, group, or subscriber ID change?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "changed",
              "label": "Payer, group, or subscriber ID changed"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "unchanged",
              "label": "Everything matches the record on file"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Did the payer, group, or subscriber ID change?"
        },
        {
          "detail": "Update payer, group, and subscriber ID in the practice record, then run a fresh eligibility check under the new plan details.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Update the record and re-verify eligibility"
        },
        {
          "detail": "Does the new plan require a full benefits breakdown?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "New payer or plan on file"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "no",
              "label": "Same payer, only administrative details changed"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does the new plan require a full benefits breakdown?"
        },
        {
          "detail": "Hand off to the full benefits breakdown entry protocol, since this is effectively a new plan on file requiring a complete re-verification.",
          "id": "s8",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Route to the full benefits breakdown protocol"
        },
        {
          "detail": "Routed to full benefits breakdown",
          "id": "s9",
          "kind": "step",
          "title": "Routed to full benefits breakdown"
        },
        {
          "detail": "Mark the account for a phone eligibility check before treatment is provided, since the plan may have changed even though no new card was presented.",
          "id": "s10",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Flag the account for phone verification"
        },
        {
          "detail": "Flagged for phone verification, refresh incomplete",
          "id": "s11",
          "kind": "step",
          "title": "Flagged for phone verification, refresh incomplete"
        },
        {
          "detail": "Mark the account as refreshed for the new plan year with no change, dated for audit purposes.\n\nRecord: refresh confirmation date on the patient account",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm no change and mark the account refreshed"
        },
        {
          "detail": "Refresh confirmed, no plan change",
          "id": "s13",
          "kind": "step",
          "title": "Refresh confirmed, no plan change"
        },
        {
          "detail": "Log the updated payer, group, and subscriber ID with the effective date in the patient's insurance record.\n\nRecord: updated plan fields in the patient insurance record",
          "id": "s14",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the updated plan details"
        },
        {
          "detail": "Plan details updated for the new year",
          "id": "s15",
          "kind": "step",
          "title": "Plan details updated for the new year"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Annual insurance card and subscriber refresh — January and each new plan year — cards re-scanned, subscriber and group verified.",
      "title": "Annual insurance card and subscriber refresh",
      "trigger": "January and each new plan year — cards re-scanned, subscriber and group verified",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State prompt-pay and assignment-of-benefits statutes (varies; e.g. California Ins. Code §10123.13, H&S §1371)",
          "source": "State prompt-pay and assignment-of-benefits statutes (varies; e.g. California Ins. Code §10123.13, H&S §1371)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10123.13.&lawCode=INS"
        },
        {
          "kind": "generic",
          "label": "Generic contract fee-schedule administration practice — the practice's own signed payer participation agreement is the governing document; no federal standard sets the fee amounts themselves — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic contract fee-schedule administration practice — the practice's own signed payer participation agreement is the governing document; no federal standard sets the fee amounts themselves"
          },
          "source": "Generic contract fee-schedule administration practice — the practice's own signed payer participation agreement is the governing document; no federal standard sets the fee amounts themselves — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 60,
      "frequency": "annual",
      "id": "ivb-013",
      "kind": "operational",
      "materials": [
        "new fee schedule document from the payer",
        "signed participation agreement",
        "fee schedule change log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Receive the fee schedule from the payer via portal, mail, or contract renewal packet, and note its effective date.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Receive the new or updated fee schedule"
        },
        {
          "detail": "Compare the fee schedule against the current signed participation agreement to confirm plan name, tier, and effective date match.\n\nWhy: Loading the wrong fee schedule underpays or overcharges every patient on that plan until it is caught.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the fee schedule matches the signed contract terms",
          "why": "Loading the wrong fee schedule underpays or overcharges every patient on that plan until it is caught."
        },
        {
          "detail": "Check: exam and periodic exam codes; prophylaxis and periodontal maintenance codes; the two or three most common restorative and crown codes; any code with an unusually large change from the prior schedule.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Spot-check a sample of common procedure fees"
        },
        {
          "detail": "The office manager reviews the spot-check results and the contract match, then approves loading the schedule practice-wide. The schedule is never loaded without this sign-off, since it changes the expected payment on every claim tied to that plan.\n\nWhy: A fee schedule error is silent and systemic — it affects every patient on the plan until the next verification catches it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager approves the fee schedule before it is loaded.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager approves the fee schedule before it is loaded",
          "why": "A fee schedule error is silent and systemic — it affects every patient on the plan until the next verification catches it."
        },
        {
          "detail": "Enter or import the approved fee schedule into the practice management system under the correct payer and plan, effective on the contract date.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Load the fee schedule into the practice system"
        },
        {
          "detail": "Generate a report comparing the loaded fees against the source schedule for the full procedure list to catch any entry errors.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Run a post-load verification report"
        },
        {
          "detail": "Does the loaded schedule match the source document exactly?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "matches",
              "label": "Loaded fees match the source schedule exactly"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "mismatch",
              "label": "One or more entries do not match"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does the loaded schedule match the source document exactly?"
        },
        {
          "detail": "Send billing and front desk the effective date and a summary of significant fee changes so patient estimates reflect the new schedule immediately.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify billing and front desk of the new schedule"
        },
        {
          "detail": "Log the payer, effective date, who approved it, and who loaded it in the fee schedule change log for audit purposes.\n\nRecord: fee schedule change log entry",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the load in the fee schedule change log"
        },
        {
          "detail": "Fee schedule loaded, verified, and logged",
          "id": "s10",
          "kind": "step",
          "title": "Fee schedule loaded, verified, and logged"
        },
        {
          "detail": "Fix any mismatched entries in the practice system and re-run the verification report until it matches the source schedule exactly.",
          "id": "s11",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Correct load errors and re-run the report"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "PPO fee schedule loading and annual update — A contract renews or a new fee schedule is received from a payer.",
      "title": "PPO fee schedule loading and annual update",
      "trigger": "A contract renews or a new fee schedule is received from a payer",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "CMS NPPES / NPI requirements 45 CFR 162.410",
          "source": "CMS NPPES / NPI requirements 45 CFR 162.410",
          "url": "https://nppes.cms.hhs.gov/"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "ivb-014",
      "kind": "operational",
      "materials": [
        "NPPES online system login",
        "updated practice or provider documentation",
        "payer provider-data update forms"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "insurance-coordinator",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify that the practice address, taxonomy code, ownership, or a provider's legal name has changed, triggering the federal 30-day update requirement.\n\nWhy: 45 CFR 162.410 requires NPPES data to be kept current; stale data causes claim rejections and can itself be treated as a compliance finding.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify a change requiring an NPPES update",
          "why": "45 CFR 162.410 requires NPPES data to be kept current; stale data causes claim rejections and can itself be treated as a compliance finding."
        },
        {
          "detail": "Collect: new practice address and phone, if changed; new taxonomy code, if changed; updated ownership or authorized official information; updated provider legal name and supporting documentation.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather the updated information"
        },
        {
          "detail": "Confirm the accuracy of the updated information with the treating dentist before submission, particularly the taxonomy code and ownership details.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Verify the change details with the dentist"
        },
        {
          "detail": "The compliance officer or practice owner confirms the update is accurate and complete before it is submitted to NPPES, since an inaccurate submission can itself trigger a compliance review.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before submitting the NPPES update.",
            "role": "compliance officer or practice owner",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before submitting the NPPES update"
        },
        {
          "detail": "Log into the NPPES online system and submit the change within 30 days of the triggering event, saving the confirmation screen or number.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the update through the NPPES system"
        },
        {
          "detail": "Send the updated information to each contracted payer's provider-data update channel so claims are not rejected for a data mismatch.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Notify contracted payers of the change"
        },
        {
          "detail": "Allow a few business days for the NPPES change to process, then verify the public NPPES record reflects the update.",
          "id": "s7",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 259200,
          "title": "Wait for NPPES confirmation"
        },
        {
          "detail": "Does the NPPES record now show the update?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "confirmed",
              "label": "Public record reflects the update"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "not-confirmed",
              "label": "Public record still shows the old information"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the NPPES record now show the update?"
        },
        {
          "detail": "Log the change type, submission date, confirmation date, and who approved and submitted it in the compliance change log.\n\nRecord: NPPES change log entry",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the completed update"
        },
        {
          "detail": "NPPES update submitted, confirmed, and logged within 30 days",
          "id": "s10",
          "kind": "step",
          "title": "NPPES update submitted, confirmed, and logged within 30 days"
        },
        {
          "detail": "Contact the NPPES help desk to check the status of the submission and resubmit if it did not process.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Follow up on an unprocessed submission"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "NPPES/NPI record update within 30 days of a change — The practice address, taxonomy, ownership or a provider name changes.",
      "title": "NPPES/NPI record update within 30 days of a change",
      "trigger": "The practice address, taxonomy, ownership or a provider name changes",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "CMS NPPES / NPI requirements 45 CFR 162.410",
          "source": "CMS NPPES / NPI requirements 45 CFR 162.410",
          "url": "https://nppes.cms.hhs.gov/"
        },
        {
          "kind": "regulation",
          "label": "Medicaid provider requirements 42 CFR Part 455",
          "source": "Medicaid provider requirements 42 CFR Part 455",
          "url": "https://www.ecfr.gov/current/title-42/part-455"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "ivb-015",
      "kind": "operational",
      "materials": [
        "credentialing application — standardized profile or payer-specific",
        "license, DEA, malpractice, and continuing-education documentation",
        "credentialing tracking log",
        "compliance calendar"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "insurance-coordinator",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify that a new provider is joining the practice, a payer has sent a recredentialing packet, or the standard attestation cycle — commonly every two to three years — is due.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify a credentialing or recredentialing trigger"
        },
        {
          "detail": "Gather: current state dental license and DEA registration; malpractice insurance certificate; diploma and residency or continuing-education documentation; work history with any gaps explained; NPI and NPPES confirmation; a federal exclusion screen — check the provider against the OIG List of Excluded Individuals/Entities and the SAM.gov exclusion list, and document the check date and result.\n\nWhy: 42 CFR Part 455 program-integrity screening requires providers to be checked against federal exclusion databases before enrollment; credentialing an excluded provider risks billing a federal program improperly.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the credentialing file",
          "why": "42 CFR Part 455 program-integrity screening requires providers to be checked against federal exclusion databases before enrollment; credentialing an excluded provider risks billing a federal program improperly."
        },
        {
          "detail": "Complete or update the standardized credentialing application used by most payers, or each payer's individual application, keeping data consistent across every submission.\n\nWhy: Inconsistent answers across payer applications are the most common cause of credentialing delay.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Complete the standardized credentialing application",
          "why": "Inconsistent answers across payer applications are the most common cause of credentialing delay."
        },
        {
          "detail": "The provider being credentialed personally reviews the application for accuracy and signs the attestation; office staff never sign the attestation on the provider's behalf.\n\nWhy: Payers require the licensed provider's own attestation of accuracy; a proxy signature can void the credentialing and expose the practice.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Provider reviews and signs the attestation before submission.",
            "role": "provider being credentialed",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Provider reviews and signs the attestation before submission",
          "why": "Payers require the licensed provider's own attestation of accuracy; a proxy signature can void the credentialing and expose the practice."
        },
        {
          "detail": "Submit the completed, signed application to each targeted payer and record the submission date and any application or tracking number.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Submit the application to each payer"
        },
        {
          "detail": "Enter the provider, payer, submission date, and expected decision window into the credentialing tracking log.\n\nRecord: credentialing tracking log entry",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the credentialing status"
        },
        {
          "detail": "Allow the payer's standard credentialing timeline, commonly 60 to 120 days, checking status at 30-day intervals.",
          "id": "s7",
          "kind": "timer",
          "role": "insurance-coordinator",
          "timer_seconds": 2592000,
          "title": "Wait for the payer's credentialing decision"
        },
        {
          "detail": "What is the payer's credentialing status?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "approved",
              "label": "Approved"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "pending-over-90",
              "label": "Still pending after 90 days"
            },
            {
              "advised": false,
              "goto": "s13",
              "id": "denied",
              "label": "Denied"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "What is the payer's credentialing status?"
        },
        {
          "detail": "Log the payer's approved participation effective date and confirm it in the practice management system so claims are not submitted as out-of-network before that date.",
          "id": "s9",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the approved effective date"
        },
        {
          "detail": "Add the next attestation or recredentialing due date to the compliance calendar, typically two to three years out per payer requirements.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Set the recredentialing reminder"
        },
        {
          "detail": "Credentialing approved, effective date recorded, next cycle scheduled",
          "id": "s11",
          "kind": "step",
          "title": "Credentialing approved, effective date recorded, next cycle scheduled"
        },
        {
          "detail": "Call the payer's credentialing line for a status update after 90 days with no decision, and notify the office manager if still unresolved.",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Escalate a stalled application"
        },
        {
          "detail": "Bring the denial reason to the provider to decide whether to appeal, correct a specific deficiency, or hold off reapplying.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Review a credentialing denial with the provider"
        },
        {
          "detail": "How should the denial be addressed?",
          "forks": [
            {
              "advised": true,
              "goto": "s15",
              "id": "appeal",
              "label": "Appeal the denial"
            },
            {
              "advised": false,
              "goto": "s17",
              "id": "hold",
              "label": "Hold and reapply later"
            }
          ],
          "id": "s14",
          "kind": "fork",
          "role": "dentist",
          "title": "How should the denial be addressed?"
        },
        {
          "detail": "Submit the payer's required appeal documentation addressing the denial reason and update the tracking log with the appeal date.",
          "id": "s15",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "File a credentialing appeal"
        },
        {
          "detail": "Credentialing appeal filed and tracked",
          "id": "s16",
          "kind": "step",
          "title": "Credentialing appeal filed and tracked"
        },
        {
          "detail": "Log the denial reason and the decision not to appeal in the credentialing log so the plan is not resubmitted prematurely.\n\nRecord: denial outcome in the credentialing log",
          "id": "s17",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the denial outcome"
        },
        {
          "detail": "Denial recorded, no appeal filed",
          "id": "s18",
          "kind": "step",
          "title": "Denial recorded, no appeal filed"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Provider credentialing and re-credentialing with payers — A new provider joins, a plan sends a recredentialing packet, or the attestation cycle expires.",
      "title": "Provider credentialing and re-credentialing with payers",
      "trigger": "A new provider joins, a plan sends a recredentialing packet, or the attestation cycle expires",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State prompt-pay and assignment-of-benefits statutes (varies; e.g. California Ins. Code §10123.13, H&S §1371) — discount medical/dental plan organizations are regulated separately from insurance in most states",
          "source": "State prompt-pay and assignment-of-benefits statutes (varies; e.g. California Ins. Code §10123.13, H&S §1371) — discount medical/dental plan organizations are regulated separately from insurance in most states",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=10123.13.&lawCode=INS"
        },
        {
          "kind": "generic",
          "label": "Generic front-office practice — distinguishing a discount membership plan (no claims filed, no benefit payment) from a licensed insurance benefit plan is a standard front-desk intake step, not a public-standard requirement — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic front-office practice — distinguishing a discount membership plan (no claims filed, no benefit payment) from a licensed insurance benefit plan is a standard front-desk intake step, not a public-standard requirement"
          },
          "source": "Generic front-office practice — distinguishing a discount membership plan (no claims filed, no benefit payment) from a licensed insurance benefit plan is a standard front-desk intake step, not a public-standard requirement — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 8,
      "frequency": "as-needed",
      "id": "ivb-016",
      "kind": "operational",
      "materials": [
        "discount plan participation list and fee schedule",
        "patient card presented at check-in"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Front desk reviews the card presented and checks whether it is a licensed dental benefit plan (insurance) or a discount or membership dental plan.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Review the card presented at check-in"
        },
        {
          "detail": "Is the card insurance or a discount plan?",
          "forks": [
            {
              "advised": false,
              "goto": "s9",
              "id": "insurance",
              "label": "It is a licensed insurance benefit plan"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "discount",
              "label": "It is a discount or membership plan, not insurance"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the card insurance or a discount plan?"
        },
        {
          "detail": "Tell the patient in plain language that a discount plan is not insurance — it does not file claims or pay benefits, it simply provides a pre-negotiated fee reduction at participating practices.\n\nWhy: Patients often expect a discount card to behave like insurance; setting expectations up front avoids a disputed bill later.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Explain the difference to the patient",
          "why": "Patients often expect a discount card to behave like insurance; setting expectations up front avoids a disputed bill later."
        },
        {
          "detail": "Check the practice's discount-plan participation list to confirm this specific plan and its negotiated fee schedule are on file.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm the practice participates in this discount plan"
        },
        {
          "detail": "Does the practice participate in this discount plan?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "participates",
              "label": "Practice participates in this plan"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "not-participate",
              "label": "Practice does not participate in this plan"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does the practice participate in this discount plan?"
        },
        {
          "detail": "Pull the discount plan's negotiated fee schedule and apply it to the planned procedures to build the patient's out-of-pocket estimate.",
          "id": "s6",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Apply the discount plan's fee schedule to the estimate"
        },
        {
          "detail": "Note the discount plan name, membership ID, and that no claim will be filed, on the patient's account so billing does not attempt an insurance submission.\n\nRecord: discount plan flag and membership ID on the patient account",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Record the discount plan on the account"
        },
        {
          "detail": "Discount plan applied, no claim to be filed",
          "id": "s8",
          "kind": "step",
          "title": "Discount plan applied, no claim to be filed"
        },
        {
          "detail": "If the card is in fact insurance, route the case to the standard eligibility verification protocol instead of handling it as a discount plan.",
          "id": "s9",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Route to standard insurance verification"
        },
        {
          "detail": "Routed to standard insurance verification",
          "id": "s10",
          "kind": "step",
          "title": "Routed to standard insurance verification"
        },
        {
          "detail": "Inform the patient the practice does not participate in this specific discount plan and quote the standard fee for the planned service.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Quote the standard fee"
        },
        {
          "detail": "Standard fee quoted, discount not applicable",
          "id": "s12",
          "kind": "step",
          "title": "Standard fee quoted, discount not applicable"
        }
      ],
      "subclass": "insurance-verification-and-benefits",
      "summary": "Patient presents a discount dental plan card (not insurance) — A card at check-in turns out to be a discount plan rather than a benefit plan.",
      "title": "Patient presents a discount dental plan card (not insurance)",
      "trigger": "A card at check-in turns out to be a discount plan rather than a benefit plan",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "source": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "url": "https://www.ecfr.gov/current/title-21/part-872"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "lab-001",
      "kind": "clinical",
      "materials": [
        "work-order form (paper or PMS-generated)",
        "shade guide",
        "intraoral scan or impression",
        "photographs if taken"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pull the chart for the completed prep or scan; confirm which tooth/teeth, arch, and restoration type the lab needs to fabricate.\n\nWhy: A prescription written from memory instead of the chart is the most common source of a wrong-tooth remake.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Identify the case ready to send",
          "why": "A prescription written from memory instead of the chart is the most common source of a wrong-tooth remake."
        },
        {
          "detail": "Complete: patient identifier, tooth number(s) (universal or FDI, state which), restoration type, material, shade (base + any characterization notes), margin design, occlusal scheme, due date, and requesting dentist name.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Draft the prescription fields"
        },
        {
          "detail": "Attach the digital scan file reference or physical impression/model, plus any shade photographs or design sketches taken chairside.\n\nWhy: The written prescription and the physical/digital record must travel together — a lab receiving one without the other has to guess or call back, adding delay.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Attach supporting records",
          "why": "The written prescription and the physical/digital record must travel together — a lab receiving one without the other has to guess or call back, adding delay."
        },
        {
          "detail": "The treating dentist reads the completed prescription against the chart and signs (wet or verified electronic signature) before the case leaves the office.\n\nWhy: A lab prescription is a legal work order under state dental practice acts — an unsigned or dentist-unreviewed prescription is not a valid authorization to fabricate.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs the prescription.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs the prescription",
          "why": "A lab prescription is a legal work order under state dental practice acts — an unsigned or dentist-unreviewed prescription is not a valid authorization to fabricate."
        },
        {
          "detail": "Is the prescription complete and signed?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "complete",
              "label": "Yes — all fields filled and signed"
            },
            {
              "goto": "s9",
              "id": "incomplete",
              "label": "No — a field is missing or unsigned"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the prescription complete and signed?"
        },
        {
          "detail": "Case number, patient identifier, tooth/teeth, material, due date, and prescription completion timestamp are recorded in the lab tracking log or PMS lab module.\n\nRecord: Case number, patient identifier, tooth/teeth, material, due date, and prescription completion timestamp are recorded in the lab tracking log or PMS lab module.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the prescription in the case tracking system"
        },
        {
          "detail": "The signed prescription and attached records are handed to whoever packages and ships the case (see the outgoing case disinfection and shipment protocol).",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Hand off to outgoing case packaging"
        },
        {
          "detail": "Case is ready for disinfection, packaging and shipment.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Prescription complete"
        },
        {
          "detail": "Flag the missing field or signature and hand the prescription back to the dentist before it can move to shipping.\n\nWhy: Fixing a gap now is minutes; discovering it after shipment costs the whole turnaround cycle.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Return the prescription to the dentist for completion",
          "why": "Fixing a gap now is minutes; discovering it after shipment costs the whole turnaround cycle."
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Written lab prescription — tooth, material, shade, design, due date, dentist signature — A case is ready to send to a laboratory.",
      "title": "Written lab prescription — tooth, material, shade, design, due date, dentist signature",
      "trigger": "A case is ready to send to a laboratory",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC infection-control guidelines — disinfection of impressions and prostheses before send and on receipt",
          "source": "CDC infection-control guidelines — disinfection of impressions and prostheses before send and on receipt",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "lab-002",
      "kind": "clinical",
      "materials": [
        "EPA-registered surface/immersion disinfectant labeled for the impression material",
        "leak-resistant, labeled shipping pouch",
        "shipping box and courier label",
        "case tracking log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Verify the case has the completed, dentist-signed prescription from the written-prescription protocol before packaging begins.\n\nWhy: Packaging a case without confirming the prescription is present risks shipping an unauthorized or incomplete order.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the signed prescription is attached",
          "why": "Packaging a case without confirming the prescription is present risks shipping an unauthorized or incomplete order."
        },
        {
          "detail": "Apply the EPA-registered disinfectant labeled for the specific impression material (alginate, PVS, or digital-model printed piece) for the manufacturer's stated contact time before packaging.\n\nWhy: Impressions and models carry saliva and blood; CDC infection-control guidance requires disinfection before the item leaves clinical space, protecting lab staff who handle it next.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the impression, model or appliance",
          "why": "Impressions and models carry saliva and blood; CDC infection-control guidance requires disinfection before the item leaves clinical space, protecting lab staff who handle it next."
        },
        {
          "detail": "Place the disinfected item in a labeled, leak-resistant pouch or container appropriate to the material, cushioned to prevent damage in transit.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Package the disinfected case"
        },
        {
          "detail": "Attach a shipping label with the practice return address, case number, and due date; keep patient identifiers limited to what the lab needs (case number rather than full chart detail where the case number alone is sufficient).\n\nWhy: Minimum-necessary labeling limits PHI exposure to couriers and lab intake staff who do not need clinical detail to route the case.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Label the outer package",
          "why": "Minimum-necessary labeling limits PHI exposure to couriers and lab intake staff who do not need clinical detail to route the case."
        },
        {
          "detail": "Case number, disinfection method and timestamp, ship date, courier or pickup method, and expected lab receipt date are recorded in the tracking log.\n\nRecord: Case number, disinfection method and timestamp, ship date, courier or pickup method, and expected lab receipt date are recorded in the tracking log.",
          "id": "s5",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the shipment"
        },
        {
          "detail": "Is the case ready for pickup or drop-off?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "ready",
              "label": "Yes — package labeled and logged"
            },
            {
              "goto": "s2",
              "id": "not-ready",
              "label": "No — missing disinfection or label step"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Is the case ready for pickup or drop-off?"
        },
        {
          "detail": "Place the package in the outgoing pickup area or hand directly to the courier at the scheduled time.",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Hand off to courier or scheduled pickup"
        },
        {
          "detail": "Case is en route to the laboratory and logged on the tracking board.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Case shipped"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Outgoing case disinfection, packaging, labeling and shipment log — An impression, model or scan-based case is leaving the office.",
      "title": "Outgoing case disinfection, packaging, labeling and shipment log",
      "trigger": "An impression, model or scan-based case is leaving the office",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA business associate rules 45 CFR 164.502(e)/164.504(e) for labs receiving PHI",
          "source": "HIPAA business associate rules 45 CFR 164.502(e)/164.504(e) for labs receiving PHI",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-C"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "lab-003",
      "kind": "clinical",
      "materials": [
        "intraoral scanner export",
        "lab's secure upload portal or file-transfer credentials",
        "case file naming convention"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "lab-liaison",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Before any digital PHI-bearing file is transferred, confirm the receiving laboratory has a signed HIPAA business associate agreement on file.\n\nWhy: A lab that fabricates from patient scan data is a business associate under 45 CFR 164.502(e); transferring PHI without a BAA on file is a compliance gap, not a workflow shortcut.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm a business associate agreement is on file for this lab.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm a business associate agreement is on file for this lab",
          "why": "A lab that fabricates from patient scan data is a business associate under 45 CFR 164.502(e); transferring PHI without a BAA on file is a compliance gap, not a workflow shortcut."
        },
        {
          "detail": "Export the intraoral scan or design file from the scanner software in the format the lab's portal accepts.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Export the digital scan file"
        },
        {
          "detail": "Check the export for embedded patient name, date of birth or other identifiers beyond what the lab needs; strip or replace with the case number where the software allows it.\n\nWhy: Minimum-necessary PHI transfer means sending only what the lab needs to fabricate — a case number typically suffices without the patient's full name in the file itself.",
          "id": "s3",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Review and minimize embedded metadata",
          "why": "Minimum-necessary PHI transfer means sending only what the lab needs to fabricate — a case number typically suffices without the patient's full name in the file itself."
        },
        {
          "detail": "Rename the export using the practice's convention (case number, tooth/teeth, date) so the lab's intake staff can match it to the written prescription.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Apply the file naming convention"
        },
        {
          "detail": "Log in to the lab's designated secure upload portal or file-transfer system and upload the named file, referencing the case number from the written prescription.",
          "id": "s5",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Upload to the lab's secure portal"
        },
        {
          "detail": "Did the portal confirm successful upload?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "confirmed",
              "label": "Yes — portal shows the file received"
            },
            {
              "goto": "s9",
              "id": "failed",
              "label": "No — upload failed or unconfirmed"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Did the portal confirm successful upload?"
        },
        {
          "detail": "Case number, file name, upload timestamp, and portal confirmation reference are recorded in the tracking log.\n\nRecord: Case number, file name, upload timestamp, and portal confirmation reference are recorded in the tracking log.",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the digital transfer"
        },
        {
          "detail": "Lab has received the digital file and can begin fabrication once the written prescription is matched.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Digital case transferred"
        },
        {
          "detail": "Retry the upload once; if it fails again, contact the practice's IT support to check portal connectivity or credentials.",
          "id": "s9",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Retry the upload or escalate to IT"
        },
        {
          "detail": "IT support checks network connectivity, portal credentials, and file size/format limits, then confirms with the lab-liaison when the path is restored.",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "IT support diagnoses the transfer failure"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Digital scan and file transfer to the lab (file naming, minimum-necessary PHI, portal upload) — A digital case is ready to send.",
      "title": "Digital scan and file transfer to the lab (file naming, minimum-necessary PHI, portal upload)",
      "trigger": "A digital case is ready to send",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "lab-004",
      "kind": "clinical",
      "materials": [
        "shade guide (natural light or shade-matching device)",
        "camera or intraoral camera",
        "diagram or digital design markup tool"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the case is an anterior restoration, veneer, or other esthetic case where shade and contour communication beyond the base prescription matters to the outcome.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Identify the case as esthetic-critical"
        },
        {
          "detail": "Take the shade at the start of the appointment, before rubber dam placement or extended isolation dries the tooth, using consistent natural or color-corrected lighting.\n\nWhy: A dehydrated tooth reads lighter than its true shade; shade taken late in a long appointment is a documented cause of shade-mismatch remakes.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Take the shade before the tooth dehydrates",
          "why": "A dehydrated tooth reads lighter than its true shade; shade taken late in a long appointment is a documented cause of shade-mismatch remakes."
        },
        {
          "detail": "Capture: shade tab held next to the target tooth, retracted view, full smile view, and any adjacent teeth needed for contour/translucency reference.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Capture the standard photo set"
        },
        {
          "detail": "The dentist adds written or diagram notes on contour, incisal translucency, characterization, and any specific requests beyond the standard prescription.\n\nWhy: Photos alone leave room for the lab technician to guess intent; a dentist's written design intent resolves ambiguity before fabrication rather than after a failed try-in.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist adds design notes",
          "why": "Photos alone leave room for the lab technician to guess intent; a dentist's written design intent resolves ambiguity before fabrication rather than after a failed try-in."
        },
        {
          "detail": "Attach the shade notes, photo set, and dentist design notes to the case record alongside the written prescription.",
          "id": "s5",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Compile the shade and design package"
        },
        {
          "detail": "The dentist reviews the compiled shade/design package once more before it ships with the case, confirming nothing was mis-transcribed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the package matches clinical intent.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the package matches clinical intent"
        },
        {
          "detail": "Is the shade/design package complete and confirmed?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "Yes — ready to attach to shipment"
            },
            {
              "goto": "s3",
              "id": "no",
              "label": "No — missing an item"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Is the shade/design package complete and confirmed?"
        },
        {
          "detail": "Case number, shade taken, photo count, and design-note summary are recorded alongside the prescription log entry.\n\nRecord: Case number, shade taken, photo count, and design-note summary are recorded alongside the prescription log entry.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the shade and design package"
        },
        {
          "detail": "Package is ready to travel with the case to the lab.",
          "id": "s9",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Shade and design communication complete"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Shade, design and photo communication to the lab — An esthetic case needs shade and design detail beyond the prescription.",
      "title": "Shade, design and photo communication to the lab",
      "trigger": "An esthetic case needs shade and design detail beyond the prescription",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        },
        {
          "kind": "generic",
          "label": "Generic office-management practice for schedule-versus-vendor-status reconciliation, described in words since no public standard governs internal tracking-board format. — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic office-management practice for schedule-versus-vendor-status reconciliation, described in words since no public standard governs internal tracking-board format."
          },
          "source": "Generic office-management practice for schedule-versus-vendor-status reconciliation, described in words since no public standard governs internal tracking-board format. — Practice policy — no published authority governs this step."
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "daily",
      "id": "lab-005",
      "kind": "clinical",
      "materials": [
        "lab case tracking board or PMS lab module",
        "schedule for the next 5–7 days"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Open the tracking board or PMS lab module listing every case currently out with a lab, its due date, and its associated seat appointment.",
          "id": "s1",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Open the lab case tracking board"
        },
        {
          "detail": "Compare each open case's due date against the patient's scheduled seat/delivery appointment for the next 5–7 days.\n\nWhy: A case can be logged as 'sent' and forgotten; cross-checking against the schedule surfaces the ones actually at risk of missing an appointment.",
          "id": "s2",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Cross-check against the upcoming schedule",
          "why": "A case can be logged as 'sent' and forgotten; cross-checking against the schedule surfaces the ones actually at risk of missing an appointment."
        },
        {
          "detail": "Is each case on track for its due date?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "on-track",
              "label": "On track — due date is comfortably before the seat appointment"
            },
            {
              "goto": "s6",
              "id": "at-risk",
              "label": "At risk — due date is within 24–48 hours of the seat appointment with no confirmation"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Is each case on track for its due date?"
        },
        {
          "detail": "Each case's status (on-track, at-risk, received) and the date of today's review are recorded on the board.\n\nRecord: Each case's status (on-track, at-risk, received) and the date of today's review are recorded on the board.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Update the tracking board"
        },
        {
          "detail": "Tracking board reflects current status for every open case; at-risk cases are flagged for follow-up.",
          "id": "s5",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Daily review complete"
        },
        {
          "detail": "Mark the case as at-risk on the tracking board and note it for a status call or portal check with the lab that day.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Flag the case for lab follow-up"
        },
        {
          "detail": "Tell the scheduler which appointment may need contingency planning if the case does not arrive in time.\n\nWhy: The scheduler needs early warning to hold a rescheduling option open rather than learning about it the day before.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Notify the scheduler of an at-risk seat appointment",
          "why": "The scheduler needs early warning to hold a rescheduling option open rather than learning about it the day before."
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Lab case tracking board daily review — Daily — every open case is checked against due date and seat appointment.",
      "title": "Lab case tracking board daily review",
      "trigger": "Daily — every open case is checked against due date and seat appointment",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC infection-control guidelines — disinfection of impressions and prostheses before send and on receipt",
          "source": "CDC infection-control guidelines — disinfection of impressions and prostheses before send and on receipt",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "lab-006",
      "kind": "clinical",
      "materials": [
        "EPA-registered surface disinfectant",
        "original written prescription for the case",
        "model or die if returned with the case"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Open the package from the lab and locate the case, any returned model or die, and the lab's paperwork.",
          "id": "s1",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Open the incoming package"
        },
        {
          "detail": "Disinfect the returned prosthesis, appliance or model with an EPA-registered disinfectant appropriate to the material before it is handled further or brought to clinical areas.\n\nWhy: A case returning from a lab has been outside the office's infection-control chain; CDC guidance treats it as needing disinfection on receipt just as on send.",
          "id": "s2",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Disinfect the case on receipt",
          "why": "A case returning from a lab has been outside the office's infection-control chain; CDC guidance treats it as needing disinfection on receipt just as on send."
        },
        {
          "detail": "Check the tooth/teeth, material, and shade on the returned case against the written prescription for mismatches.",
          "id": "s3",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Verify the case against the original prescription"
        },
        {
          "detail": "Does the case match the prescription?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "match",
              "label": "Yes — case matches tooth, material and shade ordered"
            },
            {
              "goto": "s9",
              "id": "mismatch",
              "label": "No — tooth, material or shade does not match"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Does the case match the prescription?"
        },
        {
          "detail": "If a model or die was returned with the case, verify the restoration seats correctly on the model before the patient's delivery appointment.\n\nWhy: Catching a fit problem on the model avoids discovering it chairside with the patient present.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Check fit on the model, if returned",
          "why": "Catching a fit problem on the model avoids discovering it chairside with the patient present."
        },
        {
          "detail": "The treating dentist visually reviews the case (shade, contour, margins as visible) and confirms it is acceptable to proceed toward the delivery appointment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews the case for clinical acceptability.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews the case for clinical acceptability"
        },
        {
          "detail": "Receipt date, disinfection confirmation, prescription-match result, and dentist review outcome are recorded on the tracking board.\n\nRecord: Receipt date, disinfection confirmation, prescription-match result, and dentist review outcome are recorded on the tracking board.",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the case receipt"
        },
        {
          "detail": "Case is disinfected, matched to the prescription, and cleared for delivery appointment prep.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Case received and verified"
        },
        {
          "detail": "Do not schedule or prep for delivery; hand the mismatched case and prescription to the dentist to decide whether it can be adjusted or must go back to the lab.\n\nWhy: Proceeding to a delivery appointment with a mismatched case wastes the patient's chair time and risks seating the wrong restoration.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Flag the mismatch to the dentist before scheduling delivery",
          "why": "Proceeding to a delivery appointment with a mismatched case wastes the patient's chair time and risks seating the wrong restoration."
        },
        {
          "detail": "Case does not proceed to delivery prep until the mismatch is resolved with the lab.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Case held for lab correction"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Receiving a lab case — disinfect, inspect, verify against the prescription and model fit — A package arrives from the lab.",
      "title": "Receiving a lab case — disinfect, inspect, verify against the prescription and model fit",
      "trigger": "A package arrives from the lab",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e)) — governs the case the delay affects",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e)) — governs the case the delay affects",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        },
        {
          "kind": "generic",
          "label": "Generic office-management practice for vendor-delay contingency and patient rescheduling, described in words since no public standard governs this internal workflow. — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic office-management practice for vendor-delay contingency and patient rescheduling, described in words since no public standard governs this internal workflow."
          },
          "source": "Generic office-management practice for vendor-delay contingency and patient rescheduling, described in words since no public standard governs this internal workflow. — Practice policy — no published authority governs this step."
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "lab-007",
      "kind": "clinical",
      "materials": [
        "lab case tracking board",
        "lab contact information",
        "patient contact information",
        "provisional/temporary restoration materials if a remake temporary is needed"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "scheduler",
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Double-check the mailroom/front desk and tracking board to confirm the case truly has not arrived, rather than being logged late.",
          "id": "s1",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Confirm the case is genuinely not received"
        },
        {
          "detail": "Call or message the lab's case-status line, referencing the case number, and ask for a firm ship date and tracking number if available.",
          "id": "s2",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Contact the lab for status"
        },
        {
          "detail": "Can the lab confirm arrival before the appointment?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "will-arrive",
              "label": "Yes — lab confirms it will arrive in time"
            },
            {
              "goto": "s7",
              "id": "will-not-arrive",
              "label": "No — lab cannot confirm timely arrival"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Can the lab confirm arrival before the appointment?"
        },
        {
          "detail": "Keep the case flagged on the tracking board and check again before the end of the business day; if it does not arrive, proceed to notify the scheduler of the delay.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Monitor for arrival"
        },
        {
          "detail": "Did the case arrive by end of day?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "arrived",
              "label": "Yes — case arrived, proceed to receiving protocol"
            },
            {
              "goto": "s7",
              "id": "not-arrived",
              "label": "No — still not arrived"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Did the case arrive by end of day?"
        },
        {
          "detail": "Case is now in the receiving protocol; original appointment stands.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Case arrived — no reschedule needed"
        },
        {
          "detail": "Tell the scheduler the case will not arrive in time so the patient's delivery appointment can be reworked before the patient shows up.\n\nWhy: The patient needs to be reached before their appointment time, not discover the delay in the waiting room.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Notify the scheduler of the confirmed delay",
          "why": "The patient needs to be reached before their appointment time, not discover the delay in the waiting room."
        },
        {
          "detail": "The dentist reviews whether the patient's existing provisional or temporary restoration can safely extend to a new delivery date or needs to be redone at the rescheduled visit.\n\nWhy: A delayed lab case can leave a patient on a temporary restoration longer than planned; the dentist decides if that is clinically acceptable or needs an interim fix.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Assess whether the patient's provisional/temporary needs attention",
          "why": "A delayed lab case can leave a patient on a temporary restoration longer than planned; the dentist decides if that is clinically acceptable or needs an interim fix."
        },
        {
          "detail": "Front desk calls the patient, explains the delay, and offers a new delivery appointment once the lab confirms a firm arrival date.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the patient to reschedule"
        },
        {
          "detail": "Case number, original due date, lab's revised ship date, patient reschedule outcome, and provisional assessment are recorded in the tracking log.\n\nRecord: Case number, original due date, lab's revised ship date, patient reschedule outcome, and provisional assessment are recorded in the tracking log.",
          "id": "s10",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the delay and resolution"
        },
        {
          "detail": "Patient rescheduled, provisional assessed, and lab delay logged for the quarterly quality review.",
          "id": "s11",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Delay resolved with reschedule"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Case not received the day before the seat appointment — The tracking board shows a case missing 24 hours before delivery — patient rescheduling and provisional check.",
      "title": "Case not received the day before the seat appointment",
      "trigger": "The tracking board shows a case missing 24 hours before delivery — patient rescheduling and provisional check",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        },
        {
          "kind": "generic",
          "label": "Generic appointment-preparation checklisting, described in words since no public standard governs internal chairside prep routines. — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic appointment-preparation checklisting, described in words since no public standard governs internal chairside prep routines."
          },
          "source": "Generic appointment-preparation checklisting, described in words since no public standard governs internal chairside prep routines. — Practice policy — no published authority governs this step."
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "lab-008",
      "kind": "clinical",
      "materials": [
        "received and verified lab case",
        "adjustment instruments (articulating paper, burs, polishing kit)",
        "delivery/seating checklist",
        "patient chart"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Locate tomorrow's delivery appointment on the schedule and pull both the received lab case and the corresponding patient chart.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Pull the case and the patient's chart"
        },
        {
          "detail": "Has the case completed receiving and quality check?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "verified",
              "label": "Yes — case was disinfected, matched and dentist-reviewed on receipt"
            },
            {
              "goto": "s8",
              "id": "not-verified",
              "label": "No — case has not completed the receiving protocol"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Has the case completed receiving and quality check?"
        },
        {
          "detail": "Set out articulating paper, adjustment burs, polishing kit, and any cement or bonding materials the delivery procedure will need.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Assemble seating and adjustment instruments"
        },
        {
          "detail": "Check the chart and prescription for any dentist notes on occlusal adjustment expectations, patient anxiety flags, or a planned bite check sequence.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Review any special delivery notes"
        },
        {
          "detail": "Confirm the patient is on the schedule for the expected delivery time and appointment length matches the procedure.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the patient's appointment"
        },
        {
          "detail": "Case number and appointment date are marked prep-complete on the tracking board so the front desk and dentist see it is ready.\n\nRecord: Case number and appointment date are marked prep-complete on the tracking board so the front desk and dentist see it is ready.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Log delivery prep as complete"
        },
        {
          "detail": "Case, instruments and chart are ready for tomorrow's delivery appointment.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Delivery appointment prepped"
        },
        {
          "detail": "Do not proceed with delivery prep until the case has been disinfected, matched to the prescription and reviewed by the dentist.\n\nWhy: Preparing an unverified case for delivery risks discovering a fit or shade mismatch chairside instead of the day before.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Route the case through the receiving protocol first",
          "why": "Preparing an unverified case for delivery risks discovering a fit or shade mismatch chairside instead of the day before."
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Appliance or prosthesis delivery appointment prep — A delivery appointment is tomorrow.",
      "title": "Appliance or prosthesis delivery appointment prep",
      "trigger": "A delivery appointment is tomorrow",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "source": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "url": "https://www.ecfr.gov/current/title-21/part-872"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "lab-009",
      "kind": "clinical",
      "materials": [
        "try-in photos",
        "shade tab photo",
        "articulated models or digital scan",
        "remake request form",
        "prescription copy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check fit, margins, contact, occlusion, shade and contour against the original written prescription and the patient's mouth chairside.\n\nWhy: A remake decision has to be made against the original spec, not memory, so nothing is over- or under-corrected.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Evaluate the try-in against the prescription",
          "why": "A remake decision has to be made against the original spec, not memory, so nothing is over- or under-corrected."
        },
        {
          "detail": "Is the case acceptable or does it need to go back to the lab?",
          "forks": [
            {
              "goto": "s11",
              "id": "accept",
              "label": "Acceptable — proceed to seat or next lab step"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "reject",
              "label": "Reject — needs remake or adjustment"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the case acceptable or does it need to go back to the lab?"
        },
        {
          "detail": "Mark the cause: impression/scan error, prescription ambiguity, shade mismatch, lab fabrication error, model damage in transit, or occlusal adjustment needed at try-in.\n\nWhy: Root-cause coding is what turns individual remakes into a lab quality trend the practice can act on (protocol lab-012).",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Categorize the root cause",
          "why": "Root-cause coding is what turns individual remakes into a lab quality trend the practice can act on (protocol lab-012)."
        },
        {
          "detail": "Take a photo of the try-in showing the specific problem (open margin, shade next to a shade tab, contour) before removing anything from the mouth.\n\nWhy: A photo is unambiguous evidence for the lab and for the office's own remake-rate record; verbal description alone gets lost in translation.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Photograph the discrepancy",
          "why": "A photo is unambiguous evidence for the lab and for the office's own remake-rate record; verbal description alone gets lost in translation."
        },
        {
          "detail": "Enter case number, original prescription reference, root-cause category, specific correction needed, and attach the photo(s); state whether a new impression/scan is required or the lab can correct from existing records.\n\nRecord: Remake request logged against the original case with root-cause code and attached photo evidence.",
          "id": "s5",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Complete the remake request form"
        },
        {
          "detail": "The dentist reviews and signs the remake request — clinical direction to the lab, including any occlusal or shade correction, is a licensed clinical judgment and is never sent on the assistant's or liaison's own authority.\n\nWhy: A remake instruction changes what gets fabricated for a patient; it carries the same weight as the original prescription.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the remake request before it is sent.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the remake request before it is sent",
          "why": "A remake instruction changes what gets fabricated for a patient; it carries the same weight as the original prescription."
        },
        {
          "detail": "Does the remake need a new impression or scan?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-new-records",
              "label": "Lab can correct from existing records"
            },
            {
              "goto": "s12",
              "id": "new-records",
              "label": "New impression/scan needed"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Does the remake need a new impression or scan?"
        },
        {
          "detail": "Transmit the signed remake request, root-cause note, photos, and any new impression/scan through the same secure channel used for the original case.\n\nWhy: Using the same disinfection/transfer discipline as a new case keeps the remake from becoming a shortcut around infection-control or minimum-necessary-PHI rules.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send the remake request and any new records to the lab",
          "why": "Using the same disinfection/transfer discipline as a new case keeps the remake from becoming a shortcut around infection-control or minimum-necessary-PHI rules."
        },
        {
          "detail": "Add the remake to the daily tracking board (lab-005) with a new due date, flagged as a remake so it is not double-counted as a first-time case in turnaround metrics.\n\nRecord: Tracking board entry updated: remake flag set, new due date, linked to original case number.",
          "id": "s9",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Log the remake on the tracking board with a new expected due date"
        },
        {
          "detail": "Remake logged and sent",
          "id": "s10",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Remake logged and sent"
        },
        {
          "detail": "Case accepted — proceed",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Case accepted — proceed"
        },
        {
          "detail": "Route the patient back through a fresh impression or digital scan per the disinfection and digital-transfer protocols before resending to the lab (protocols lab-002/lab-003).",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to the impression/scan capture step"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Remake or adjustment request to the lab with root-cause note — The dentist rejects fit, shade or contour at try-in, or the lab asks for clarification.",
      "title": "Remake or adjustment request to the lab with root-cause note",
      "trigger": "The dentist rejects fit, shade or contour at try-in, or the lab asks for clarification",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e)) — the prescription record the reconciliation matches invoice line items against",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e)) — the prescription record the reconciliation matches invoice line items against",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        },
        {
          "kind": "generic",
          "label": "— practice bookkeeping/reconciliation workflow, no authority applies — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic functional equivalent — practice bookkeeping/reconciliation workflow, no authority applies"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Direct read of DOCS/TECHNICAL_PROTOCOLS.md (all section headers: Infection Control, Radiology, Anesthesia, Restorative, Periodontal, Pediatric, Emergency, Documentation Standards) confirms no mention of invoices, reconciliation, or bookkeeping anywhere in the file (grep for 'invoice' and 'reconcil' returns no matches).",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md — generic functional equivalent for practice bookkeeping/reconciliation workflow (no clinical public floor applies to invoice matching itself)",
              "url": null
            }
          },
          "source": "— practice bookkeeping/reconciliation workflow, no authority applies — Practice policy — no published authority governs this step."
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "lab-010",
      "kind": "clinical",
      "materials": [
        "lab statement",
        "case tracking board export",
        "lab fee schedule/price list",
        "accounting software or ledger"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Log the statement date, total billed, and number of line items when it arrives from the lab; route a copy to the lab liaison.\n\nWhy: A dated receipt record establishes the reconciliation window and protects against a late or missing statement going unnoticed.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Receive and log the monthly lab statement",
          "why": "A dated receipt record establishes the reconciliation window and protects against a late or missing statement going unnoticed."
        },
        {
          "detail": "For every line on the statement, find the matching case on the tracking board (case number, patient, procedure, date sent) and confirm it was actually received by the practice.\n\nWhy: The lab liaison — not billing — has the clinical context to know whether a billed case was truly delivered, remade, or never sent.",
          "id": "s2",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Match each line item to a tracked case",
          "why": "The lab liaison — not billing — has the clinical context to know whether a billed case was truly delivered, remade, or never sent."
        },
        {
          "detail": "Compare the billed price for each item against the current lab price list/agreement on file.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Check each matched line against the agreed fee schedule"
        },
        {
          "detail": "Are there unmatched, mispriced, or duplicate line items?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "clean",
              "label": "Statement matches — no discrepancies"
            },
            {
              "goto": "s7",
              "id": "discrepancy",
              "label": "Discrepancy found (unmatched case, wrong price, duplicate, or a remake billed as new)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "billing",
          "title": "Are there unmatched, mispriced, or duplicate line items?"
        },
        {
          "detail": "Mark the statement reconciled and release payment for the undisputed (and any newly corrected) total on the standard payment schedule.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Approve the statement for payment"
        },
        {
          "detail": "Statement reconciled",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Statement reconciled"
        },
        {
          "detail": "List each disputed line with its category: no matching case, price above agreed schedule, duplicate billing, or a remake charged as a full new case.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Flag each discrepancy with its type"
        },
        {
          "detail": "Send the flagged line items to the lab's billing contact with the case numbers and the specific discrepancy for each, and request a corrected statement or credit.\n\nWhy: Routing disputes through the liaison keeps one point of contact with the lab so the same discrepancy is not raised twice by two different staff members.",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send the dispute list to the lab for correction",
          "why": "Routing disputes through the liaison keeps one point of contact with the lab so the same discrepancy is not raised twice by two different staff members."
        },
        {
          "detail": "Record the disputed line items and amounts in the accounting ledger as pending, and pay only the undisputed balance on the normal payment schedule.\n\nRecord: Ledger entry: disputed line items, amounts held, date sent to lab, resolution status.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Log the dispute and hold the disputed amount from payment"
        },
        {
          "detail": "Allow up to 15 business days for the lab to respond with a corrected statement, credit memo, or explanation before escalating.",
          "id": "s10",
          "kind": "timer",
          "role": "billing",
          "timer_seconds": 1814400,
          "title": "Wait for the lab's corrected statement or credit"
        },
        {
          "detail": "Did the lab resolve the dispute?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "resolved",
              "label": "Corrected statement/credit received — reconcile and close"
            },
            {
              "goto": "s12",
              "id": "unresolved",
              "label": "No response or unresolved after 15 business days"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "billing",
          "title": "Did the lab resolve the dispute?"
        },
        {
          "detail": "An unresolved lab billing dispute past the response window is escalated for a decision on payment hold, vendor conversation, or (per protocol lab-011) a lab-relationship review.\n\nWhy: A dispute the lab will not resolve is a vendor-management decision, not a line-item bookkeeping one, and needs someone with authority over the vendor relationship.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate an unresolved billing dispute to the office manager or practice owner.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "office-manager",
          "title": "Escalate an unresolved billing dispute to the office manager or practice owner",
          "why": "A dispute the lab will not resolve is a vendor-management decision, not a line-item bookkeeping one, and needs someone with authority over the vendor relationship."
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Monthly lab invoice reconciliation against cases — The monthly lab statement is received.",
      "title": "Monthly lab invoice reconciliation against cases",
      "trigger": "The monthly lab statement is received",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "source": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "url": "https://www.ecfr.gov/current/title-21/part-872"
        },
        {
          "kind": "regulation",
          "label": "HIPAA business associate rules 45 CFR 164.502(e)/164.504(e) for labs receiving PHI",
          "source": "HIPAA business associate rules 45 CFR 164.502(e)/164.504(e) for labs receiving PHI",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-C"
        },
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e))",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "quarterly",
      "id": "lab-011",
      "kind": "clinical",
      "materials": [
        "FDA 21 CFR Part 807 registration lookup",
        "lab agreement/contract template",
        "HIPAA business associate agreement template",
        "material and price list",
        "turnaround and remake-rate report"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "lab-liaison",
        "dentist",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Is this a new lab onboarding or a quarterly review of an existing lab?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "onboard",
              "label": "New or replacement lab onboarding"
            },
            {
              "goto": "s8",
              "id": "review",
              "label": "Quarterly quality review of current labs"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is this a new lab onboarding or a quarterly review of an existing lab?"
        },
        {
          "detail": "Confirm the laboratory is registered as a device establishment (FDA 21 CFR Part 807) and can produce dental devices under 21 CFR Part 872 before sending any case.\n\nWhy: Sending prescription work to an unregistered fabricator is a regulatory exposure for the ordering dentist, not just the lab.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the lab's device establishment registration",
          "why": "Sending prescription work to an unregistered fabricator is a regulatory exposure for the ordering dentist, not just the lab."
        },
        {
          "detail": "Confirm the materials the lab offers (metals, ceramics, resins) match what the practice prescribes, and request material certification/alloy content documentation availability (feeds protocol lab-013).",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review the lab's material offerings and certifications"
        },
        {
          "detail": "Sign a written agreement covering pricing, standard turnaround times, remake policy, and shipping/insurance terms; file a copy with the practice's vendor records.\n\nRecord: Signed lab agreement and price schedule filed in vendor records.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Execute the lab agreement and pricing schedule"
        },
        {
          "detail": "A laboratory that receives patient-identifiable case information (name, images, or scans tied to identity) is a business associate under 45 CFR 164.502(e); a signed BAA must be on file before the first case ships.\n\nWhy: Shipping the first case before the BAA is signed is a PHI-disclosure exposure the practice cannot undo after the fact.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Execute a HIPAA business associate agreement before any case is sent.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Execute a HIPAA business associate agreement before any case is sent",
          "why": "Shipping the first case before the BAA is signed is a PHI-disclosure exposure the practice cannot undo after the fact."
        },
        {
          "detail": "Route a straightforward first case through the normal outgoing/digital transfer protocols and evaluate the returned work against the prescription before relying on the lab for complex cases.\n\nWhy: A test case surfaces fit, communication, and turnaround problems before a patient's treatment plan depends on the new relationship.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send a low-risk test case and confirm turnaround and quality",
          "why": "A test case surfaces fit, communication, and turnaround problems before a patient's treatment plan depends on the new relationship."
        },
        {
          "detail": "New lab onboarded",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "New lab onboarded"
        },
        {
          "detail": "Request the current-quarter turnaround days and remake rate per lab from the office manager (produced by protocol lab-012).",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the quarterly turnaround and remake-rate report"
        },
        {
          "detail": "Review each lab's turnaround days, remake rate, and any recurring root-cause categories against the prior quarter and against the other labs the practice uses.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hold the quarterly quality review meeting"
        },
        {
          "detail": "Does any lab fall below the practice's quality or turnaround threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "acceptable",
              "label": "All labs within acceptable range — continue as-is"
            },
            {
              "goto": "s12",
              "id": "below",
              "label": "One or more labs below threshold"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does any lab fall below the practice's quality or turnaround threshold?"
        },
        {
          "detail": "Quarterly review complete",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Quarterly review complete"
        },
        {
          "detail": "Choose and document one: formal conversation with the lab about the specific gap, a probationary period with tighter case-level review, reducing case volume sent to that lab, or replacing the lab (returns to the onboarding branch for a replacement).",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Decide the corrective action for an underperforming lab"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Onboarding a new laboratory (registration, materials, agreement, turnaround) and quarterly quality review — The practice adds or replaces a laboratory, or the quarterly remake-rate review is due.",
      "title": "Onboarding a new laboratory (registration, materials, agreement, turnaround) and quarterly quality review",
      "trigger": "The practice adds or replaces a laboratory, or the quarterly remake-rate review is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e)) — the prescription/case record the turnaround and remake counts are drawn from",
          "source": "Written orders to dental technicians (Cal. Code Regs. tit. 16 §1063) and dentist prescription-signing requirement (Cal. B&P Code §1626(e)) — the prescription/case record the turnaround and remake counts are drawn from",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1063"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md contains no lab-turnaround or remake-rate content — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md contains no lab-turnaround or remake-rate content — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "DOCS/TECHNICAL_PROTOCOLS.md's table of contents (confirmed by direct read): 1. Infection Control, 2. Radiology, 3. Anesthesia, 4. Restorative, 5. Periodontal, 6. Pediatric, 7. Emergency, 8. Documentation Standards (SOAP/consent/refusal only). No lab-turnaround or remake-rate metric appears anywhere in the file.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md — generic functional equivalent for practice quality/operations metrics reporting (no clinical public floor applies to internal metrics compilation itself)",
              "url": null
            }
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md contains no lab-turnaround or remake-rate content — Practice policy — no published authority governs this step."
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "quarterly",
      "id": "lab-012",
      "kind": "clinical",
      "materials": [
        "case tracking board export",
        "remake request log (lab-009)",
        "spreadsheet or reporting tool"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Export every case marked received/delivered in the quarter, with lab name, date sent, date due, date received, and remake flag if any.\n\nWhy: Metrics need a complete closed-case set for the period, not just the cases still open on the day of reporting.",
          "id": "s1",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Pull all closed cases for the quarter from the tracking board",
          "why": "Metrics need a complete closed-case set for the period, not just the cases still open on the day of reporting."
        },
        {
          "detail": "For each case, compute days from send to receipt; average by lab and compare against the lab's agreed turnaround time.",
          "id": "s2",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Calculate turnaround days per case and average per lab"
        },
        {
          "detail": "Divide the number of cases received on or before the due date by total cases per lab.",
          "id": "s3",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Calculate on-time delivery percentage per lab"
        },
        {
          "detail": "Cross-reference the remake request log (protocol lab-009) to count remakes per lab and their root-cause categories for the same period.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull remake requests for the quarter from the remake log"
        },
        {
          "detail": "Divide remake count by total cases sent to that lab in the quarter to get a remake rate percentage; break the total down by root-cause category.\n\nWhy: Rate, not raw count, is what is comparable across labs with different case volumes.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Calculate remake rate per lab",
          "why": "Rate, not raw count, is what is comparable across labs with different case volumes."
        },
        {
          "detail": "Assemble average turnaround, on-time percentage, remake rate, and top root-cause categories per lab into a single report.\n\nRecord: Quarterly lab metrics report saved with the quarter's data, per-lab breakdown, and root-cause summary.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the quarterly metrics report"
        },
        {
          "detail": "Deliver the compiled report to the practice owner ahead of the quarterly review meeting (protocol lab-011).",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the report to the practice owner for the quarterly quality review"
        },
        {
          "detail": "Quarterly metrics compiled and delivered",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Quarterly metrics compiled and delivered"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Lab turnaround and remake-rate metrics — The quarter closes and lab turnaround days and remake rate are tallied per lab.",
      "title": "Lab turnaround and remake-rate metrics",
      "trigger": "The quarter closes and lab turnaround days and remake rate are tallied per lab",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "source": "FDA 21 CFR Part 872 dental devices; 21 CFR Part 807 registration for device fabrication",
          "url": "https://www.ecfr.gov/current/title-21/part-872"
        },
        {
          "kind": "regulation",
          "label": "HIPAA business associate rules 45 CFR 164.502(e)/164.504(e) for labs receiving PHI",
          "source": "HIPAA business associate rules 45 CFR 164.502(e)/164.504(e) for labs receiving PHI",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-C"
        }
      ],
      "class": "laboratory-communication",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "lab-013",
      "kind": "clinical",
      "materials": [
        "material certificate from the lab",
        "case prescription record",
        "material composition/allergen reference sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "lab-liaison",
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Note whether the patient is asking out of general curiosity/documentation need, or because they suspect an allergic or sensitivity reaction to a restoration.\n\nWhy: The two situations route differently — one is informational, the other has a clinical safety component that needs the dentist.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the patient's question",
          "why": "The two situations route differently — one is informational, the other has a clinical safety component that needs the dentist."
        },
        {
          "detail": "Is an allergy or adverse reaction suspected?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "allergy",
              "label": "Allergy or reaction suspected"
            },
            {
              "goto": "s4",
              "id": "curiosity",
              "label": "General information request, no symptoms"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is an allergy or adverse reaction suspected?"
        },
        {
          "detail": "The dentist assesses the patient's symptoms and history; if the presentation is consistent with a significant allergic reaction (facial swelling, difficulty breathing), stop this protocol and follow the office's medical-emergency response.\n\nWhy: Handing a patient a materials list without a clinical evaluation risks the patient self-diagnosing or self-treating instead of being assessed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist evaluates the suspected reaction before any material information is given as guidance.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist evaluates the suspected reaction before any material information is given as guidance",
          "why": "Handing a patient a materials list without a clinical evaluation risks the patient self-diagnosing or self-treating instead of being assessed."
        },
        {
          "detail": "Pull the original prescription and any material certificate the lab provided for that specific case (alloy content, ceramic type, resin composition).",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Look up the case's prescription and lab-issued material record"
        },
        {
          "detail": "Is a lab-issued material certificate already on file?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "on-file",
              "label": "Certificate already on file"
            },
            {
              "goto": "s10",
              "id": "request",
              "label": "Not on file — must be requested from the lab"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "lab-liaison",
          "title": "Is a lab-issued material certificate already on file?"
        },
        {
          "detail": "Prepare a plain-language summary of the material composition for the patient, drawn directly from the lab's certificate — never from memory or assumption about what the lab typically uses.\n\nWhy: Materials information given to a patient must trace to the lab's actual documentation for that restoration, since guessing wrong on an allergen is a real harm.\n\nRecord: Material certificate and patient summary filed in the case record; copy given to the patient on request.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Prepare the patient-facing material information",
          "why": "Materials information given to a patient must trace to the lab's actual documentation for that restoration, since guessing wrong on an allergen is a real harm."
        },
        {
          "detail": "The dentist reviews the prepared material summary against the lab's certificate for accuracy before any patient-facing delivery, on every path through this protocol including general information requests.\n\nWhy: No path may reach patient-facing material or allergen information without a licensed clinical review, even when the request started as a curiosity/documentation inquiry rather than a suspected reaction.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the material summary before it reaches the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the material summary before it reaches the patient",
          "why": "No path may reach patient-facing material or allergen information without a licensed clinical review, even when the request started as a curiosity/documentation inquiry rather than a suspected reaction."
        },
        {
          "detail": "The dentist reviews the material summary for accuracy and delivers it to the patient, framing any allergy concern as something to follow up on with the patient's physician or an allergist if symptoms are present.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews and delivers the information to the patient"
        },
        {
          "detail": "Material information documented and delivered",
          "id": "s9",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Material information documented and delivered"
        },
        {
          "detail": "Send the case number to the lab and request the material composition or alloy-content certificate for that specific restoration.",
          "id": "s10",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Request the material certificate from the lab"
        },
        {
          "detail": "Allow up to 5 business days for the lab to return the certificate before following up.",
          "id": "s11",
          "kind": "timer",
          "role": "lab-liaison",
          "timer_seconds": 604800,
          "title": "Wait for the lab to return the material certificate"
        }
      ],
      "subclass": "dental-laboratory-coordination",
      "summary": "Material and alloy content documentation and patient-requested certificate — A patient asks what a restoration is made of, or an allergy is suspected.",
      "title": "Material and alloy content documentation and patient-requested certificate",
      "trigger": "A patient asks what a restoration is made of, or an allergy is suspected",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ANSI Z136.3 — Safe Use of Lasers in Health Care (laser safety officer, controlled area, eyewear by wavelength, plume control)",
          "source": "ANSI Z136.3 — Safe Use of Lasers in Health Care (laser safety officer, controlled area, eyewear by wavelength, plume control)"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §3203 (injury and illness prevention program)",
          "source": "Cal/OSHA Title 8 §3203 (injury and illness prevention program)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California Title 16 CCR auxiliary scope-of-practice regulations — board-approved coursework required before a hygienist or assistant operates a laser",
          "source": "Dental Board of California Title 16 CCR auxiliary scope-of-practice regulations — board-approved coursework required before a hygienist or assistant operates a laser",
          "url": "https://www.dbc.ca.gov/"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 120,
      "frequency": "once",
      "id": "les-001",
      "kind": "clinical",
      "materials": [
        "written laser safety program document",
        "device manufacturer operating manual",
        "controlled-area signage",
        "wavelength-matched protective eyewear inventory list",
        "laser safety officer training certificate template",
        "device log binder or digital equivalent"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "compliance-officer",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Name one clinical staff member (typically the dentist) as laser safety officer, responsible for the written program, device inventory, eyewear stock and incident reporting.\n\nWhy: ANSI Z136.3 requires a single named accountable person so laser safety does not fall between roles.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Designate a laser safety officer",
          "why": "ANSI Z136.3 requires a single named accountable person so laser safety does not fall between roles."
        },
        {
          "detail": "Document each device on hand, its wavelength and class, controlled-area setup for each operatory it is used in, eyewear requirements by wavelength, plume evacuation method, and the incident-reporting path.\n\nWhy: A written program is the standard's baseline artifact and is what an inspector or reviewer asks to see first.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft or update the written laser safety program",
          "why": "A written program is the standard's baseline artifact and is what an inspector or reviewer asks to see first."
        },
        {
          "detail": "Place a laser-in-use warning sign at the operatory entrance whenever a device is active, and stock one pair of wavelength-matched protective eyewear per person present (operator, assistant, patient) plus spares.\n\nWhy: The controlled area and matched eyewear are the two physical controls the standard requires before any beam is fired.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Post controlled-area signage and stock wavelength-matched eyewear",
          "why": "The controlled area and matched eyewear are the two physical controls the standard requires before any beam is fired."
        },
        {
          "detail": "Verify: every laser and electrosurgery unit is listed with wavelength/class; eyewear inventory matches every listed wavelength; each operatory that uses a device has signage; the incident path names who receives a report; the device log location is recorded.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the program covers every device and every operatory"
        },
        {
          "detail": "A licensed dentist reviews and signs the written laser safety program before it goes into effect.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the written program.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the written program"
        },
        {
          "detail": "Signed written laser safety program, laser safety officer designation, and a calendar reminder for annual review or whenever a device is added or removed.\n\nRecord: Signed written laser safety program, laser safety officer designation, and a calendar reminder for annual review or whenever a device is added or removed.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the signed program and set a review reminder"
        },
        {
          "detail": "Program active",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Program active"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Laser safety program and laser safety officer designation — The practice acquires its first dental laser, or the designated laser safety officer leaves.",
      "title": "Laser safety program and laser safety officer designation",
      "trigger": "The practice acquires its first dental laser, or the designated laser safety officer leaves",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ANSI Z136.3 — Safe Use of Lasers in Health Care (controlled area, eyewear by wavelength, test fire before use on the patient)",
          "source": "ANSI Z136.3 — Safe Use of Lasers in Health Care (controlled area, eyewear by wavelength, test fire before use on the patient)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.133 — eye and face protection",
          "source": "OSHA 29 CFR 1910.133 — eye and face protection",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.133"
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 1040.10–1040.11 — laser product performance standards",
          "source": "FDA 21 CFR 1040.10–1040.11 — laser product performance standards",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-J/part-1040/section-1040.10"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "les-002",
      "kind": "clinical",
      "materials": [
        "dental laser unit",
        "wavelength-matched protective eyewear for operator, assistant and patient",
        "laser-in-use signage",
        "test-fire target (tongue blade or equivalent)",
        "device log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Place the warning sign so anyone approaching the operatory sees it before entering.\n\nWhy: Warns anyone entering unannounced to put on eyewear first or stay out.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Post laser-in-use signage at the operatory entrance",
          "why": "Warns anyone entering unannounced to put on eyewear first or stay out."
        },
        {
          "detail": "Check: dentist wearing matched eyewear; assistant wearing matched eyewear; patient wearing matched eyewear or eye shields; any other person in the room wearing matched eyewear.\n\nWhy: Mismatched or missing eyewear is the single most common cause of laser eye injury reports.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm wavelength-matched eyewear on everyone present",
          "why": "Mismatched or missing eyewear is the single most common cause of laser eye injury reports."
        },
        {
          "detail": "Verify the planned procedure, tooth or site, and laser settings match the chart before activating the device. This protocol assumes laser contraindications (photosensitizing medication, active mucosal or herpetic lesion at the site, and similar pre-laser clearance items) were already reviewed at treatment planning — confirm that review is on file rather than re-screening here.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm procedure consent and device settings against the treatment plan"
        },
        {
          "detail": "Fire the laser briefly onto a tongue blade or equivalent non-reflective target, away from the patient, to confirm expected output before using it intraorally.\n\nWhy: Confirms the device is functioning as expected and gives the operator a feel for output before working near tissue.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Test-fire the laser on a target away from the patient",
          "why": "Confirms the device is functioning as expected and gives the operator a feel for output before working near tissue."
        },
        {
          "detail": "Date, device, wavelength/power setting, procedure, and eyewear confirmation for all present, in the device log.\n\nRecord: Date, device, wavelength/power setting, procedure, and eyewear confirmation for all present, in the device log.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Log the procedure start, device settings and eyewear confirmation"
        },
        {
          "detail": "Cleared to proceed with the laser procedure",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Cleared to proceed with the laser procedure"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Laser procedure setup: controlled area, wavelength-matched eyewear and test fire — A soft-tissue or whitening laser procedure is about to start in an operatory.",
      "title": "Laser procedure setup: controlled area, wavelength-matched eyewear and test fire",
      "trigger": "A soft-tissue or whitening laser procedure is about to start in an operatory",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "OSHA Technical Manual Section III Chapter 6 (laser hazards) and OSHA/NIOSH surgical smoke and laser plume guidance",
          "source": "OSHA Technical Manual Section III Chapter 6 (laser hazards) and OSHA/NIOSH surgical smoke and laser plume guidance",
          "url": "https://www.osha.gov/laser-hazards"
        },
        {
          "kind": "open_standard",
          "label": "ANSI Z136.3 — Safe Use of Lasers in Health Care (plume control)",
          "source": "ANSI Z136.3 — Safe Use of Lasers in Health Care (plume control)"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "les-003",
      "kind": "clinical",
      "materials": [
        "smoke evacuator with high-efficiency filter",
        "N95 or higher-filtration mask for staff",
        "surgical mask for the patient when not actively treated",
        "filter replacement log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Hold or clip the evacuator suction tip as close to the tissue as the device and access allow — manufacturer instructions and OSHA/NIOSH plume guidance both call for minimal standoff distance — on the near side of the plume, in the airflow path away from staff faces. PENDING_HITL_REVIEW: a licensed clinician should confirm the standoff distance against the specific device's manufacturer instructions before this becomes a fixed numeric target.\n\nWhy: Capture efficiency drops sharply as distance from the source increases.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Position the smoke evacuator nozzle close to the treatment site",
          "why": "Capture efficiency drops sharply as distance from the source increases."
        },
        {
          "detail": "Check the filter log for the last replacement date against the manufacturer's rated hours or procedure count.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the evacuator filter is within its rated service life"
        },
        {
          "detail": "Check: operator and assistant wearing N95 or higher-filtration mask; patient's mask on when not actively being treated; evacuator running before the device is activated, not after.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm respiratory protection for staff and patient"
        },
        {
          "detail": "Do not pause the evacuator between activations of the device during the same procedure.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Keep the evacuator running for the full duration of tissue vaporization"
        },
        {
          "detail": "Date, device, evacuator run confirmed for the full procedure, filter status, and staff/patient respiratory-protection compliance, in the filter replacement log or device log.\n\nRecord: Date, device, evacuator run confirmed for the full procedure, filter status, and staff/patient respiratory-protection compliance, in the filter replacement log or device log.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Log plume-control compliance for the procedure"
        },
        {
          "detail": "Plume controlled for the procedure",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Plume controlled for the procedure"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Laser plume evacuation and respiratory protection — A laser or electrosurgery unit will vaporize tissue and generate plume.",
      "title": "Laser plume evacuation and respiratory protection",
      "trigger": "A laser or electrosurgery unit will vaporize tissue and generate plume",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA recommendations on preventing surgical fires (oxidizer–fuel–ignition triad, oxygen-enriched environments)",
          "source": "FDA recommendations on preventing surgical fires (oxidizer–fuel–ignition triad, oxygen-enriched environments)",
          "url": "https://www.fda.gov/medical-devices/surgery-devices/preventing-surgical-fires"
        },
        {
          "kind": "open_standard",
          "label": "ANSI Z136.3 — Safe Use of Lasers in Health Care (ignition-source precautions)",
          "source": "ANSI Z136.3 — Safe Use of Lasers in Health Care (ignition-source precautions)"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "les-004",
      "kind": "clinical",
      "materials": [
        "CO2 (carbon dioxide) fire extinguisher sized for the operatory — preferred near energized equipment because it is non-conductive and leaves no corrosive residue on devices, per FDA surgical-fire guidance",
        "basin or wet gauze for smothering a small fire",
        "supplemental oxygen delivery equipment",
        "alcohol-free prep alternative"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If a fire is already burning: remove the ignition source, stop the flow of oxygen at its source, smother with wet gauze or an extinguisher, and evacuate the patient. Call 911 for any fire that does not extinguish immediately or that caused a burn.\n\nWhy: An active fire is addressed before any preventive checklist — this gate exists to interrupt the normal flow if the trigger describes a fire already underway.",
          "gate": {
            "ack": "I confirm I have completed this step as written: If fire has already started, stop and respond to the fire first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "If fire has already started, stop and respond to the fire first",
          "why": "An active fire is addressed before any preventive checklist — this gate exists to interrupt the normal flow if the trigger describes a fire already underway."
        },
        {
          "detail": "Confirm which oxidizer (supplemental oxygen or nitrous/oxygen), fuel (drapes, gauze, alcohol-based prep, patient hair) and ignition source (laser, electrosurgery tip) will be present together.\n\nWhy: A surgical fire needs all three; naming them is how the team catches the combination before it occurs.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the three elements of the fire triad before starting",
          "why": "A surgical fire needs all three; naming them is how the team catches the combination before it occurs."
        },
        {
          "detail": "Can supplemental oxygen be reduced or paused for the energy-device portion?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "reduce",
              "label": "Reduce flow or pause delivery briefly during the energy-device step, resume after"
            },
            {
              "goto": "s9",
              "id": "keep",
              "label": "Oxygen must continue (medically necessary) — proceed with added precautions"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Can supplemental oxygen be reduced or paused for the energy-device portion?"
        },
        {
          "detail": "Coordinate with whoever is administering oxygen to briefly reduce flow or divert it away from the operative field, then resume immediately after the energy device step.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Pause or reduce oxygen flow for the minimum time the energy device is active"
        },
        {
          "detail": "Avoid alcohol-based skin or mucosal prep near the ignition source; use a non-flammable alternative; keep drapes and gauze damp where they may contact the energy device.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Remove or wet down fuel sources in the field"
        },
        {
          "detail": "Dentist confirms out loud that oxygen, fuel and ignition have each been addressed before the energy device is activated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off that the fire-triad check is complete before activating the device.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off that the fire-triad check is complete before activating the device"
        },
        {
          "detail": "Date, procedure, oxygen status during the energy-device step, and confirmation the check was completed, in the chart or procedure log.\n\nRecord: Date, procedure, oxygen status during the energy-device step, and confirmation the check was completed, in the chart or procedure log.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the fire-triad check"
        },
        {
          "detail": "Cleared to proceed with the energy device",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Cleared to proceed with the energy device"
        },
        {
          "detail": "Use wet gauze around the field, avoid alcohol-based preps entirely, drape to direct any leaking oxygen away from the ignition source, and keep an extinguisher and wet gauze within reach.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "If oxygen cannot pause, isolate the field and increase fuel control"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Surgical fire prevention when supplemental oxygen meets a laser, electrosurgery unit or alcohol prep — A patient is on nasal oxygen or nitrous/oxygen and an energy device or alcohol-based prep will be used in the mouth.",
      "title": "Surgical fire prevention when supplemental oxygen meets a laser, electrosurgery unit or alcohol prep",
      "trigger": "A patient is on nasal oxygen or nitrous/oxygen and an energy device or alcohol-based prep will be used in the mouth",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Device manufacturer guidance on electromagnetic interference with implanted cardiac devices and cochlear implants — cited generically, never a brand — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Device manufacturer guidance on electromagnetic interference with implanted cardiac devices and cochlear implants — cited generically, never a brand"
          },
          "source": "Device manufacturer guidance on electromagnetic interference with implanted cardiac devices and cochlear implants — cited generically, never a brand — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 1040.10–1040.11 — laser product performance standards",
          "source": "FDA 21 CFR 1040.10–1040.11 — laser product performance standards",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-J/part-1040/section-1040.10"
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 803 — medical device adverse-event (MDR) reporting",
          "source": "FDA 21 CFR 803 — medical device adverse-event (MDR) reporting",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-803"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "les-005",
      "kind": "clinical",
      "materials": [
        "medical history form",
        "implanted-device information card (if patient has one)",
        "pulse oximeter or equivalent monitoring",
        "device manufacturer EMI guidance sheet (generic)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Ask the patient what device they have, when it was placed, and whether their cardiologist or physician has given any restrictions on electrosurgery, ultrasonic instruments or diagnostic devices.\n\nWhy: Older or unshielded devices are more susceptible to electromagnetic interference than modern shielded ones — the type and age matter to the risk.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the implanted device type and any physician restrictions",
          "why": "Older or unshielded devices are more susceptible to electromagnetic interference than modern shielded ones — the type and age matter to the risk."
        },
        {
          "detail": "Can a non-electrosurgery alternative accomplish the same clinical goal?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "alt",
              "label": "Use a hand instrument, laser, or other non-EMI modality instead"
            },
            {
              "goto": "s6",
              "id": "needed",
              "label": "Electrosurgery is clinically necessary — proceed with precautions"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Can a non-electrosurgery alternative accomplish the same clinical goal?"
        },
        {
          "detail": "Document the modality substitution and proceed with the planned treatment using the alternative instrument.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed using the non-EMI alternative"
        },
        {
          "detail": "Implanted device type, precautions or alternative modality used, and any physician clearance, in the chart.\n\nRecord: Implanted device type, precautions or alternative modality used, and any physician clearance, in the chart.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Document the implant, precautions taken, and any clearance obtained"
        },
        {
          "detail": "Procedure completed with implant precautions documented",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Procedure completed with implant precautions documented"
        },
        {
          "detail": "If the patient cannot confirm shielding or the device is an older model, contact the patient's cardiologist or implant clinic for clearance before using electrosurgery. Note: the protocol's 10-minute duration covers the administrative check when clearance is already on file or an alternative modality is used; a fresh clearance request can take substantially longer while the office waits on a physician callback, and treatment should not proceed until that clearance is received.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Obtain physician clearance if the device history is unclear or high-risk"
        },
        {
          "detail": "Prefer bipolar electrosurgery mode over monopolar whenever the procedure allows, since bipolar current stays local between the forceps tips rather than traveling through a return-pad path that can cross the implant or its leads; use short, intermittent bursts rather than continuous activation; keep the active electrode and return pad path away from the device; use the lowest effective power setting; and have monitoring equipment available. PENDING_HITL_REVIEW: confirm this precaution set against a licensed-clinician-sourced reference before treating it as fixed guidance.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Apply EMI precautions during the procedure"
        },
        {
          "detail": "Dentist confirms precautions are in place and, if sought, physician clearance is documented before activating the device.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before activating electrosurgery near the implant.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before activating electrosurgery near the implant"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Electrosurgery or ultrasonic use on a patient with a pacemaker, defibrillator or cochlear implant — A patient reports an implanted cardiac device or cochlear implant and electrosurgery, ultrasonic scaling or a pulp tester is planned.",
      "title": "Electrosurgery or ultrasonic use on a patient with a pacemaker, defibrillator or cochlear implant",
      "trigger": "A patient reports an implanted cardiac device or cochlear implant and electrosurgery, ultrasonic scaling or a pulp tester is planned",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 1040.10–1040.11 — laser product performance standards",
          "source": "FDA 21 CFR 1040.10–1040.11 — laser product performance standards",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-J/part-1040/section-1040.10"
        },
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 803 — medical device adverse-event (MDR) reporting",
          "source": "FDA 21 CFR 803 — medical device adverse-event (MDR) reporting",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-803"
        },
        {
          "kind": "open_standard",
          "label": "ANSI Z136.3 — Safe Use of Lasers in Health Care (device maintenance recommendations)",
          "source": "ANSI Z136.3 — Safe Use of Lasers in Health Care (device maintenance recommendations)"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "quarterly",
      "id": "les-006",
      "kind": "clinical",
      "materials": [
        "device manufacturer maintenance manual",
        "spare fiber tips or electrodes",
        "output test target",
        "maintenance and calibration log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the fiber tip end or electrode for cracking, discoloration, or a burred edge; cleave or replace as needed per the manufacturer manual.\n\nWhy: A damaged fiber tip changes the beam's actual output at the target even when the console display reads normal settings.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Inspect the fiber tip or electrode for damage before scheduled use",
          "why": "A damaged fiber tip changes the beam's actual output at the target even when the console display reads normal settings."
        },
        {
          "detail": "Fire the device at a standard test setting onto the calibration target, measuring output with a calibrated power meter where the practice has one, or by comparing the resulting burn/mark pattern to the manufacturer manual's reference pattern where it does not, and compare the result to the manufacturer's expected range.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Run the manufacturer's output test against the test target"
        },
        {
          "detail": "Is device output within the manufacturer's expected range?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "In range — log and return to service"
            },
            {
              "goto": "s6",
              "id": "no",
              "label": "Out of range or fiber cannot be repaired — remove from service"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is device output within the manufacturer's expected range?"
        },
        {
          "detail": "Date, device, fiber/electrode condition, output test result, and any repair or replacement, in the maintenance and calibration log.\n\nRecord: Date, device, fiber/electrode condition, output test result, and any repair or replacement, in the maintenance and calibration log.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the inspection, test result and any service action"
        },
        {
          "detail": "Maintenance cycle complete",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Maintenance cycle complete"
        },
        {
          "detail": "Tag the device as out of service, notify clinical staff, and schedule manufacturer or authorized-vendor repair.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Remove the device from service and schedule vendor service"
        },
        {
          "detail": "This role is reused generically for external equipment service (not computer/network IT) in this class — provide the vendor the device model, serial number, and description of the output or fiber issue found.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand off to the equipment service vendor"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Laser and electrosurgery device maintenance, calibration and fiber inspection log — The manufacturer service interval elapses, a fiber tip breaks, or output drifts.",
      "title": "Laser and electrosurgery device maintenance, calibration and fiber inspection log",
      "trigger": "The manufacturer service interval elapses, a fiber tip breaks, or output drifts",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA 21 CFR 803 — medical device adverse-event (MDR) reporting",
          "source": "FDA 21 CFR 803 — medical device adverse-event (MDR) reporting",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-803"
        },
        {
          "kind": "open_standard",
          "label": "ANSI Z136.3 — Safe Use of Lasers in Health Care (incident response)",
          "source": "ANSI Z136.3 — Safe Use of Lasers in Health Care (incident response)"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §3382 (eye and face protection) — post-incident review of PPE adequacy",
          "source": "Cal/OSHA Title 8 §3382 (eye and face protection) — post-incident review of PPE adequacy"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "les-007",
      "kind": "clinical",
      "materials": [
        "incident report form",
        "device log",
        "emergency eyewash station",
        "referral list for ophthalmology or urgent care"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Power off or stand down the device immediately. If the exposure is to the eye with pain, vision change, or any sign of penetrating injury, call 911 and arrange emergency transport — do not wait for the rest of this protocol.\n\nWhy: Eye injury from a laser can worsen with delay; the emergency path takes priority over documentation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop the device immediately and assess for an emergency.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Stop the device immediately and assess for an emergency",
          "why": "Eye injury from a laser can worsen with delay; the emergency path takes priority over documentation."
        },
        {
          "detail": "Does the exposure need emergency transport or can it be managed with urgent referral? When uncertain, default to the emergency path.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "urgent",
              "label": "Emergency signs present, or uncertain which applies — 911 already called (or call now), proceed to documentation after transport"
            },
            {
              "goto": "s3",
              "id": "referral",
              "label": "Clearly no emergency signs — arrange same-day ophthalmology or urgent-care referral"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the exposure need emergency transport or can it be managed with urgent referral? When uncertain, default to the emergency path."
        },
        {
          "detail": "If the exposure involves splatter or debris in addition to the beam itself, flush at the eyewash station per standard first-aid practice while arranging transport or referral.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Flush the eye at the eyewash station if there is any chemical or debris component"
        },
        {
          "detail": "Contact the ophthalmology or urgent-care referral, or confirm EMS transport status and communicate the injury mechanism to receiving staff.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Arrange the referral or confirm transport is underway"
        },
        {
          "detail": "Compliance officer reviews the incident, PPE worn at the time, and device settings before the device is used again.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review before the device returns to service.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review before the device returns to service"
        },
        {
          "detail": "Date, device, settings in use, description of the exposure, PPE status, referral or EMS transport details, and root-cause findings, in the incident report and the patient's chart.\n\nRecord: Date, device, settings in use, description of the exposure, PPE status, referral or EMS transport details, and root-cause findings, in the incident report and the patient's chart.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the incident and the referral or transport"
        },
        {
          "detail": "Incident closed and documented",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Incident closed and documented"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Laser or electrosurgery adverse event: eye exposure, unintended tissue burn or reflected beam — A beam strikes an eye or unintended tissue, eyewear was not worn, or a patient reports a burn after a laser procedure.",
      "title": "Laser or electrosurgery adverse event: eye exposure, unintended tissue burn or reflected beam",
      "trigger": "A beam strikes an eye or unintended tissue, eyewear was not worn, or a patient reports a burn after a laser procedure",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California Title 16 CCR auxiliary scope-of-practice regulations — board-approved coursework required before a hygienist or assistant operates a laser",
          "source": "Dental Board of California Title 16 CCR auxiliary scope-of-practice regulations — board-approved coursework required before a hygienist or assistant operates a laser",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "open_standard",
          "label": "ANSI Z136.3 — Safe Use of Lasers in Health Care (operator training expectations)",
          "source": "ANSI Z136.3 — Safe Use of Lasers in Health Care (operator training expectations)"
        }
      ],
      "class": "laser-energy-devices",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "once",
      "id": "les-008",
      "kind": "clinical",
      "materials": [
        "board-approved laser coursework certificate",
        "device-specific competency checklist",
        "supervised-use log",
        "state scope-of-practice reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Check the current state scope-of-practice reference for whether a hygienist or assistant may operate the specific laser function being delegated (e.g., bacterial reduction vs soft-tissue surgery).\n\nWhy: Scope varies by state and by the specific laser function — delegation itself can be out of scope even with training.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the delegated task is within the state's allowed scope for this role",
          "why": "Scope varies by state and by the specific laser function — delegation itself can be out of scope even with training."
        },
        {
          "detail": "Is the specific laser function within this role's state scope of practice?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "In scope — proceed to coursework verification"
            },
            {
              "goto": "s9",
              "id": "no",
              "label": "Out of scope for this role — task stays with the dentist"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the specific laser function within this role's state scope of practice?"
        },
        {
          "detail": "Confirm the staff member holds a current board-approved laser safety and operation course certificate before any supervised use begins.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify board-approved laser coursework is on file"
        },
        {
          "detail": "Directly supervise the staff member operating the device for the number of uses the practice's competency checklist requires, correcting technique as needed. Note: this protocol's 60-minute duration covers the scope check, coursework verification, checklist and sign-off session — the supervised-use period itself typically spans multiple separate patient encounters over the interval the practice's checklist sets, not one sitting.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Conduct and log supervised uses on the specific device"
        },
        {
          "detail": "Check: eyewear and controlled-area setup performed correctly unsupervised; test fire performed before each use; correct settings selected for the delegated procedure; plume evacuation used correctly; incident-reporting path known.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm device-specific competency checklist items"
        },
        {
          "detail": "Dentist signs the competency checklist confirming the staff member may operate the device independently for the delegated function.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on competency before independent use.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on competency before independent use"
        },
        {
          "detail": "Coursework certificate, supervised-use log, and signed competency checklist, in the staff member's training file, with a re-verification date.\n\nRecord: Coursework certificate, supervised-use log, and signed competency checklist, in the staff member's training file, with a re-verification date.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the coursework certificate and signed competency checklist"
        },
        {
          "detail": "Staff member cleared for independent delegated use",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Staff member cleared for independent delegated use"
        },
        {
          "detail": "Delegation not permitted under state scope of practice",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Delegation not permitted under state scope of practice"
        }
      ],
      "subclass": "laser-electrosurgery-and-energy-device-safety",
      "summary": "Laser operator training and competency verification before delegated use — A hygienist or assistant is asked to operate a laser (e.g., bacterial reduction, whitening activation) under state scope.",
      "title": "Laser operator training and competency verification before delegated use",
      "trigger": "A hygienist or assistant is asked to operate a laser (e.g., bacterial reduction, whitening activation) under state scope",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR §164.506 — permits PHI disclosure between providers for treatment consultation (does not prescribe clinical management content)",
          "repaired": {
            "action": "reduce",
            "evidence": "45 CFR 164.506 governs 'Uses and disclosures to carry out treatment, payment, or health care operations' — it authorizes a covered entity to use or disclose PHI for treatment activities, including consultation between health care providers, without requiring patient authorization for that purpose. It contains no clinical-management standards for drug-interaction screening or bleeding-disorder coordination.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.506 (provider-to-provider consultation)",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
            }
          },
          "source": "HIPAA 45 CFR §164.506 (Uses and disclosures to carry out treatment, payment, or health care operations). Scope: supports only the disclosure-permission step in mcg-001 (medical consultation/clearance request routed to the physician, response received, chart closed) — does NOT prescribe how to clinically manage polypharmacy/drug interactions (mcg-012) or a bleeding disorder/hematology coordination plan (mcg-013), which are clinical-guideline matters this section does not address.",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for the consultation request form — no institute template reproduced",
          "source": "Generic functional equivalent for the consultation request form — no institute template reproduced"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mcg-001",
      "kind": "clinical",
      "materials": [
        "health history form",
        "consultation request template/fax cover",
        "chart / practice management system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Review the updated health history and mark the specific condition, medication or recent event (e.g. new diagnosis, recent hospitalization, unclear medication list) that needs clarification before treatment proceeds.\n\nWhy: A vague sense of 'medically complex' does not tell the physician what question to answer.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the health-history item requiring physician input",
          "why": "A vague sense of 'medically complex' does not tell the physician what question to answer."
        },
        {
          "detail": "State the planned dental procedure, the specific medical question (e.g. 'cleared for extraction while on anticoagulant X', 'current A1c'), and a response deadline.\n\nWhy: A specific, closed question gets a faster and more useful answer than an open-ended one.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Draft the consultation request",
          "why": "A specific, closed question gets a faster and more useful answer than an open-ended one."
        },
        {
          "detail": "The treating dentist confirms the question is correctly framed and signs off before the request leaves the office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs the request before it is sent.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs the request before it is sent"
        },
        {
          "detail": "Transmit the signed request by the practice's standard secure channel (fax, secure portal, or mail) to the patient's physician or specialist.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the request to the physician's office"
        },
        {
          "detail": "Record the date sent, recipient, and expected response date in the chart and on a tracking log.\n\nRecord: Consultation request sent — date, recipient, expected response date",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the request as sent"
        },
        {
          "detail": "Hold non-urgent treatment pending a response; monitor for the return fax, portal reply, or callback.\n\nWhy: Proceeding without the answer defeats the purpose of asking.",
          "id": "s6",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 172800,
          "title": "Wait for physician response (up to 2 business days)",
          "why": "Proceeding without the answer defeats the purpose of asking."
        },
        {
          "detail": "Was a response received in time?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "Yes — response received"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "No — follow up"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was a response received in time?"
        },
        {
          "detail": "Read the response for a clear clearance, conditional clearance (with modifications), or deferral, and confirm it actually answers the question asked.\n\nWhy: A response that doesn't address the specific question sent needs a follow-up, not a rubber stamp.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Review the physician's response",
          "why": "A response that doesn't address the specific question sent needs a follow-up, not a rubber stamp."
        },
        {
          "detail": "Scan or attach the physician's written response into the chart, linked to today's treatment plan.\n\nRecord: Physician response filed and linked to the treatment plan",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "File the response in the chart"
        },
        {
          "detail": "Update the treatment plan to reflect any modifications the physician required (timing, prophylaxis, dosage adjustments) before scheduling proceeds.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Close the loop with the treatment plan"
        },
        {
          "detail": "Consultation complete and documented",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Consultation complete and documented"
        },
        {
          "detail": "Call the physician's office directly to confirm the request was received and ask for a response timeframe; re-fax if needed.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Follow up with the physician's office"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Medical consultation or clearance request, physician response and chart closure — The health history raises a question that needs the physician's input before treatment.",
      "title": "Medical consultation or clearance request, physician response and chart closure",
      "trigger": "The health history raises a question that needs the physician's input before treatment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA infective endocarditis prophylaxis statement (open)",
          "source": "AHA infective endocarditis prophylaxis statement (open)",
          "url": "https://www.ahajournals.org/doi/10.1161/CIR.0000000000000969"
        },
        {
          "kind": "open_standard",
          "label": "ADA/AAOS prosthetic joint guidance (open)",
          "source": "ADA/AAOS prosthetic joint guidance (open)",
          "url": "https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/antibiotic-prophylaxis"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "mcg-002",
      "kind": "clinical",
      "materials": [
        "updated health history",
        "current AHA cardiac-condition prophylaxis list",
        "current ADA/AAOS prosthetic joint guidance",
        "prescription pad / e-prescribing system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the updated health history for a qualifying cardiac condition (per the current AHA list), a prosthetic joint, or an immunocompromising condition or medication.\n\nWhy: The prophylaxis decision starts from the specific condition named in current guidance, not a general 'medical history' flag.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review the health history for prophylaxis-relevant conditions",
          "why": "The prophylaxis decision starts from the specific condition named in current guidance, not a general 'medical history' flag."
        },
        {
          "detail": "Which category applies?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "cardiac",
              "label": "Qualifying cardiac condition per current AHA criteria"
            },
            {
              "goto": "s10",
              "id": "joint",
              "label": "Prosthetic joint history"
            },
            {
              "goto": "s11",
              "id": "immune",
              "label": "Immunocompromising condition or medication"
            },
            {
              "goto": "s12",
              "id": "none",
              "label": "History reviewed — no qualifying condition found"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Which category applies?"
        },
        {
          "detail": "Per current AHA guidance, prophylaxis is considered only for procedures meeting this criterion in patients with a qualifying cardiac condition.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the planned procedure involves manipulation of gingival tissue, the periapical region, or oral mucosa perforation"
        },
        {
          "detail": "Is antibiotic prophylaxis indicated per current guidance?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "yes",
              "label": "Yes — premedication indicated"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "No — not indicated per current criteria"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is antibiotic prophylaxis indicated per current guidance?"
        },
        {
          "detail": "Verify no documented allergy to the standard regimen before prescribing; select an alternative regimen per current guidance if an allergy is present.\n\nWhy: Premedication for one risk must not create a new allergic-reaction risk.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm antibiotic allergy status",
          "why": "Premedication for one risk must not create a new allergic-reaction risk."
        },
        {
          "detail": "The treating dentist personally confirms the regimen, dose and allergy check before the premedication order is written — this decision is never delegated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before the prescription is written.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before the prescription is written"
        },
        {
          "detail": "Prescribe the antibiotic, dose, and timing (typically taken before the appointment) per current guidance, and confirm the patient understands when to take it.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Write the premedication order"
        },
        {
          "detail": "Record the condition, the regimen prescribed, and confirmation the patient took it before the appointment (or reschedule if not taken).\n\nRecord: Premedication order and confirmation of compliance documented in the chart",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the premedication order in the chart"
        },
        {
          "detail": "Prophylaxis decision documented; procedure may proceed",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Prophylaxis decision documented; procedure may proceed"
        },
        {
          "detail": "Per current ADA/AAOS guidance, routine antibiotic prophylaxis is not recommended for most dental patients with prosthetic joint implants; check for any documented orthopedic surgeon recommendation to the contrary.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm timing since joint replacement and any orthopedic surgeon guidance on file"
        },
        {
          "detail": "For significant immunocompromise (e.g. active chemotherapy, transplant, uncontrolled disease), the prophylaxis decision may need physician input rather than a standing protocol.\n\nWhy: Immunocompromise prophylaxis is condition-specific and often requires the treating physician's current recommendation.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Assess immunocompromise severity",
          "why": "Immunocompromise prophylaxis is condition-specific and often requires the treating physician's current recommendation."
        },
        {
          "detail": "Note in the chart which condition was reviewed and why prophylaxis was not indicated under current criteria.\n\nRecord: Prophylaxis-not-indicated rationale documented in the chart",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document that prophylaxis was not indicated"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Antibiotic prophylaxis decision — cardiac conditions, prosthetic joints, immunocompromise — A patient reports a heart condition, joint replacement or immune suppression before an invasive procedure.",
      "title": "Antibiotic prophylaxis decision — cardiac conditions, prosthetic joints, immunocompromise",
      "trigger": "A patient reports a heart condition, joint replacement or immune suppression before an invasive procedure",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOMS MRONJ position paper (open)",
          "source": "AAOMS MRONJ position paper (open)",
          "url": "https://www.aaoms.org/practice-resources/clinical-resources/medication-related-osteonecrosis-of-the-jaw/"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "mcg-004",
      "kind": "clinical",
      "materials": [
        "updated medication and oncology/osteoporosis history",
        "AAOMS MRONJ position paper (current version)",
        "referral form for oral/maxillofacial surgery when indicated"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm whether the patient is on an oral or IV bisphosphonate, denosumab, or an antiangiogenic agent, and note the duration of therapy and the indication (osteoporosis versus oncologic).\n\nWhy: MRONJ risk differs materially by drug, route, dose and duration — the same drug class carries very different risk in an osteoporosis dose versus an oncologic dose.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the specific drug, route, dose and duration",
          "why": "MRONJ risk differs materially by drug, route, dose and duration — the same drug class carries very different risk in an osteoporosis dose versus an oncologic dose."
        },
        {
          "detail": "What is the indication and risk tier?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "low",
              "label": "Lower-risk profile (e.g. oral bisphosphonate, osteoporosis dose, shorter duration)"
            },
            {
              "goto": "s10",
              "id": "high",
              "label": "Higher-risk profile (e.g. IV bisphosphonate or denosumab for oncologic indication, longer duration, or prior MRONJ)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "What is the indication and risk tier?"
        },
        {
          "detail": "Determine whether the planned treatment involves extraction, implant placement, or other bone-invasive surgery versus a non-invasive alternative.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Assess whether the planned procedure is invasive to bone"
        },
        {
          "detail": "Is a non-invasive alternative reasonable?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "alt",
              "label": "Yes — treat the tooth non-surgically where possible (e.g. root canal instead of extraction)"
            },
            {
              "goto": "s5",
              "id": "invasive",
              "label": "No — invasive procedure is necessary"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a non-invasive alternative reasonable?"
        },
        {
          "detail": "Per current AAOMS guidance, plan for atraumatic technique, primary closure where feasible, and consider a drug holiday only if directed by the prescribing physician (not unilaterally by the dentist).",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Plan modified surgical technique if invasive treatment proceeds"
        },
        {
          "detail": "The treating dentist personally confirms the risk tier and modified technique plan before any bone-invasive procedure begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before invasive treatment proceeds.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before invasive treatment proceeds"
        },
        {
          "detail": "Explain the elevated risk of delayed healing or MRONJ, the modified technique planned, and warning signs to watch for after the procedure.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss MRONJ risk with the patient before proceeding"
        },
        {
          "detail": "Record the drug history, risk tier, any specialist correspondence, and the modified technique or referral decision.\n\nRecord: MRONJ risk stratification and management plan documented",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the risk assessment and plan"
        },
        {
          "detail": "MRONJ risk assessment complete; treatment plan finalized",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "MRONJ risk assessment complete; treatment plan finalized"
        },
        {
          "detail": "Send a referral describing the drug history and the planned dental treatment to an oral and maxillofacial surgeon for a joint risk assessment before proceeding.\n\nWhy: Higher-risk antiresorptive therapy changes the surgical plan enough that it belongs with a specialist, not a standing office protocol.",
          "id": "s10",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Refer to oral and maxillofacial surgery before any invasive procedure",
          "why": "Higher-risk antiresorptive therapy changes the surgical plan enough that it belongs with a specialist, not a standing office protocol."
        },
        {
          "detail": "Hold non-urgent invasive treatment until the specialist's recommendation is received.",
          "id": "s11",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 259200,
          "title": "Await specialist guidance"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Antiresorptive or antiangiogenic patient — MRONJ risk assessment and surgical modification — A patient reports bisphosphonate, denosumab or antiangiogenic therapy.",
      "title": "Antiresorptive or antiangiogenic patient — MRONJ risk assessment and surgical modification",
      "trigger": "A patient reports bisphosphonate, denosumab or antiangiogenic therapy",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For diabetes-aware scheduling and hypoglycemia readiness in dental settings — reflects widely taught principles (morning appointments, confirm the patient ate and took medication, have glucose source on hand), not a reproduced institute protocol — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for diabetes-aware scheduling and hypoglycemia readiness in dental settings — reflects widely taught principles (morning appointments, confirm the patient ate and took medication, have glucose source on hand), not a reproduced institute protocol"
          },
          "source": "For diabetes-aware scheduling and hypoglycemia readiness in dental settings — reflects widely taught principles (morning appointments, confirm the patient ate and took medication, have glucose source on hand), not a reproduced institute protocol — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.506 (provider-to-provider consultation)",
          "source": "HIPAA 45 CFR 164.506 (provider-to-provider consultation)",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2024-title45-vol2/xml/CFR-2024-title45-vol2-sec164-506.xml"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "mcg-005",
      "kind": "clinical",
      "materials": [
        "updated health history including recent A1c if available",
        "blood glucose meter (if stocked)",
        "oral fast-acting glucose source (e.g. glucose tablets or juice) for hypoglycemia readiness"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask whether a recent A1c value is known and note the patient's typical medication and eating schedule when booking the appointment.\n\nWhy: Scheduling around the patient's medication and meal timing reduces the chance of an in-chair glucose event.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm diabetes status and recent control at scheduling",
          "why": "Scheduling around the patient's medication and meal timing reduces the chance of an in-chair glucose event."
        },
        {
          "detail": "Schedule diabetic patients earlier in the day when the practice's schedule allows, so the visit falls closer to a normal meal and medication routine.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer a morning appointment where possible"
        },
        {
          "detail": "Confirm the patient ate a normal meal, took diabetes medication as usual, and ask how they are feeling before starting treatment.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Day-of check-in questions"
        },
        {
          "detail": "Does the patient report symptoms of low blood sugar or uncertainty about their last meal/medication?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "concern",
              "label": "Yes — symptoms or uncertainty present"
            },
            {
              "goto": "s7",
              "id": "none",
              "label": "No — feeling normal, ate and medicated as usual"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the patient report symptoms of low blood sugar or uncertainty about their last meal/medication?"
        },
        {
          "detail": "Use the office glucose meter to check the patient's current level before proceeding, or reschedule if no meter is available and symptoms are present.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Check blood glucose if a meter is available"
        },
        {
          "detail": "Is the glucose level in a safe range to proceed?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "safe",
              "label": "Yes — safe to proceed"
            },
            {
              "goto": "s10",
              "id": "low",
              "label": "No — low reading or ongoing symptoms"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the glucose level in a safe range to proceed?"
        },
        {
          "detail": "Carry out the planned treatment while staying alert for signs of hypoglycemia (shakiness, sweating, confusion) during the appointment.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with treatment, monitoring for symptoms"
        },
        {
          "detail": "Record whether a glucose check was performed, the result if taken, and any hypoglycemic episode and how it was managed.\n\nRecord: Glucose status and any hypoglycemic event documented in the chart",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Document glucose status and any event"
        },
        {
          "detail": "Appointment complete with diabetes management documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Appointment complete with diabetes management documented"
        },
        {
          "detail": "Before giving anything by mouth, confirm the patient can respond appropriately and swallow safely — do not give oral glucose to a patient who is confused, unresponsive, or unable to swallow.\n\nWhy: Oral glucose given to an altered or unresponsive patient is an aspiration risk; a severe or worsening hypoglycemic episode needs EMS, not an oral treatment attempt.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "conscious",
              "label": "Yes — conscious, alert, and able to swallow safely"
            },
            {
              "advised": false,
              "goto": "s13",
              "id": "altered",
              "label": "No — altered, unresponsive, or unable to swallow safely"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient conscious, alert, and able to protect their airway and swallow safely?",
          "why": "Oral glucose given to an altered or unresponsive patient is an aspiration risk; a severe or worsening hypoglycemic episode needs EMS, not an oral treatment attempt."
        },
        {
          "detail": "Give the patient a fast-acting glucose source and wait, rechecking symptoms/glucose before deciding whether to proceed or reschedule.\n\nWhy: Treating suspected hypoglycemia before it worsens is safer than proceeding through it.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Give fast-acting oral glucose and recheck",
          "why": "Treating suspected hypoglycemia before it worsens is safer than proceeding through it."
        },
        {
          "detail": "The treating dentist personally confirms the patient's symptoms have resolved and it is safe to resume treatment before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before treatment resumes after a glucose event.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before treatment resumes after a glucose event"
        },
        {
          "detail": "Do not attempt oral glucose. Call 911 immediately, keep the patient positioned safely (e.g. on their side if unresponsive), and monitor airway and breathing until EMS arrives.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Severe hypoglycemia with an altered or unresponsive patient — call 911 now.",
            "type": "safety"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Severe hypoglycemia with an altered or unresponsive patient — call 911 now"
        },
        {
          "detail": "Call 911, describe the suspected severe hypoglycemia and the patient's level of responsiveness, and hand off care to EMS on arrival.",
          "id": "s14",
          "kind": "step",
          "role": "ems",
          "title": "Activate EMS and hand off care"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Diabetic patient — A1c review, timing, glucose check and hypoglycemia readiness — A patient with diabetes is scheduled for treatment.",
      "title": "Diabetic patient — A1c review, timing, glucose check and hypoglycemia readiness",
      "trigger": "A patient with diabetes is scheduled for treatment",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/ACOG pregnancy oral health consensus (open)",
          "source": "ADA/ACOG pregnancy oral health consensus (open)",
          "url": "https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/pregnancy"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "mcg-007",
      "kind": "clinical",
      "materials": [
        "updated health history noting pregnancy and expected trimester",
        "lead apron/thyroid collar for any radiographs taken",
        "wedge or pillow for left lateral tilt positioning in later pregnancy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Update the health history with the pregnancy status and estimated trimester or due date at intake or as soon as it is reported.\n\nWhy: Trimester materially changes what is deferred, what positioning is needed, and what medications are appropriate.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm pregnancy status and estimated trimester",
          "why": "Trimester materially changes what is deferred, what positioning is needed, and what medications are appropriate."
        },
        {
          "detail": "Is the dental need urgent (pain, infection, trauma) or elective/routine?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "urgent",
              "label": "Urgent — treat regardless of trimester with appropriate precautions"
            },
            {
              "goto": "s10",
              "id": "elective",
              "label": "Elective/routine — consider timing"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the dental need urgent (pain, infection, trauma) or elective/routine?"
        },
        {
          "detail": "In later pregnancy, tilt the patient slightly to the left side (left lateral tilt) rather than fully supine, and allow position changes as needed for comfort.\n\nWhy: Prolonged full supine positioning in later pregnancy can compress major blood vessels.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Adjust chair positioning as needed",
          "why": "Prolonged full supine positioning in later pregnancy can compress major blood vessels."
        },
        {
          "detail": "Are radiographs necessary for diagnosis or treatment?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "necessary",
              "label": "Yes — necessary for care"
            },
            {
              "goto": "s6",
              "id": "defer",
              "label": "No — can be deferred"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Are radiographs necessary for diagnosis or treatment?"
        },
        {
          "detail": "Use a lead apron and thyroid collar and limit to the radiographs necessary for diagnosis; per current guidance, necessary dental radiographs with proper shielding are considered safe during pregnancy.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Take necessary radiographs with full shielding"
        },
        {
          "detail": "Check any local anesthetic, analgesic, or antibiotic planned against current pregnancy-category guidance before prescribing.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "current pregnancy-safety medication reference"
          ],
          "role": "dentist",
          "title": "Review planned medications against current pregnancy-safety guidance"
        },
        {
          "detail": "The treating dentist personally confirms the medication review before any prescription is given to a pregnant patient — this decision is never delegated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before prescribing during pregnancy.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before prescribing during pregnancy"
        },
        {
          "detail": "Record trimester, positioning used, radiographs taken with shielding, and medications reviewed or prescribed.\n\nRecord: Pregnancy accommodations and medication review documented in the chart",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the pregnancy accommodations made"
        },
        {
          "detail": "Pregnancy-adapted treatment plan complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Pregnancy-adapted treatment plan complete"
        },
        {
          "detail": "Which trimester is the patient in?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "second",
              "label": "Second trimester — generally the preferred window for elective treatment"
            },
            {
              "goto": "s11",
              "id": "first-third",
              "label": "First or third trimester — consider deferring elective treatment"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Which trimester is the patient in?"
        },
        {
          "detail": "Discuss with the patient whether elective treatment can wait until the second trimester or after delivery, per current ADA/ACOG guidance, unless urgent.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss deferring elective treatment"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Pregnant patient — trimester timing, positioning, radiographs, medications — A patient reports pregnancy at intake or during treatment planning.",
      "title": "Pregnant patient — trimester timing, positioning, radiographs, medications",
      "trigger": "A patient reports pregnancy at intake or during treatment planning",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOMS MRONJ position paper (open) — relevant where antiresorptive/antiangiogenic oncologic therapy overlaps",
          "source": "AAOMS MRONJ position paper (open) — relevant where antiresorptive/antiangiogenic oncologic therapy overlaps",
          "url": "https://www.aaoms.org/practice-resources/clinical-resources/medication-related-osteonecrosis-of-the-jaw/"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for pre-radiation dental clearance and neutropenia precaution timing used across US dental oncology support care — no institute protocol reproduced",
          "source": "Generic functional equivalent for pre-radiation dental clearance and neutropenia precaution timing used across US dental oncology support care — no institute protocol reproduced"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mcg-008",
      "kind": "clinical",
      "materials": [
        "updated oncology treatment timeline and current blood counts if available",
        "comprehensive exam and radiograph set for pre-radiation clearance",
        "referral form to oncology team",
        "mucositis management supplies (e.g. bland rinse recommendations)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Determine whether the patient is about to start head-and-neck radiation, is about to start chemotherapy, or is already in active treatment on immunosuppressants.\n\nWhy: Pre-radiation clearance, pre-chemotherapy clearance, and in-treatment management are different protocols with different urgency.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify where the patient is in oncology treatment",
          "why": "Pre-radiation clearance, pre-chemotherapy clearance, and in-treatment management are different protocols with different urgency."
        },
        {
          "detail": "Which stage applies?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "pre-radiation",
              "label": "About to start head-and-neck radiation — needs pre-radiation dental clearance"
            },
            {
              "goto": "s7",
              "id": "active",
              "label": "Already in active chemotherapy/immunosuppression"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Which stage applies?"
        },
        {
          "detail": "Perform a full exam and radiographs to identify any teeth at risk that should be extracted before radiation begins, since post-radiation extraction risk (osteoradionecrosis) is significantly higher.\n\nWhy: Treating dental disease before radiation avoids having to extract teeth in an irradiated field later.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Complete a comprehensive pre-radiation dental exam",
          "why": "Treating dental disease before radiation avoids having to extract teeth in an irradiated field later."
        },
        {
          "detail": "Confirm with the oncology team the minimum healing window needed between any pre-radiation extractions and the start of radiation therapy.",
          "id": "s4",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Coordinate timing of extractions with the oncology team"
        },
        {
          "detail": "Send written clearance documentation to the oncology team confirming the dental status and any extractions completed before radiation starts.\n\nRecord: Pre-radiation dental clearance documented and sent to the oncology team",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the pre-radiation clearance and send it to oncology"
        },
        {
          "detail": "Oncology-coordinated visit complete",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Oncology-coordinated visit complete"
        },
        {
          "detail": "Confirm current neutrophil and platelet counts with the oncology team before performing any invasive procedure during active treatment.\n\nWhy: Invasive treatment during neutropenia or thrombocytopenia carries elevated infection and bleeding risk.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Check current blood counts before any invasive treatment",
          "why": "Invasive treatment during neutropenia or thrombocytopenia carries elevated infection and bleeding risk."
        },
        {
          "detail": "Are counts adequate for invasive treatment per the oncology team?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "adequate",
              "label": "Yes — adequate, proceed with necessary invasive treatment"
            },
            {
              "goto": "s13",
              "id": "low",
              "label": "No — counts too low, defer invasive treatment"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Are counts adequate for invasive treatment per the oncology team?"
        },
        {
          "detail": "The treating dentist personally confirms current counts and oncology-team coordination before performing any invasive procedure — this decision is never delegated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before invasive treatment during active oncology treatment.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before invasive treatment during active oncology treatment"
        },
        {
          "detail": "Proceed with the minimum necessary invasive treatment, coordinating antibiotic coverage with the oncology team if indicated.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Perform necessary invasive treatment with precautions"
        },
        {
          "detail": "Examine for mucositis and provide management guidance (e.g. bland rinses, avoiding irritating foods, pain management coordination with the oncology team) if present.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Assess for and manage oral mucositis"
        },
        {
          "detail": "Record blood counts checked, the treatment decision, any mucositis findings and management, and coordination with the oncology team.\n\nRecord: Immunocompromise management, counts, and mucositis status documented",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document the visit and coordination"
        },
        {
          "detail": "Manage the issue with the least invasive option available (e.g. medication management, temporary restoration) and recheck counts before revisiting invasive treatment.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Defer invasive treatment and manage non-surgically"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Immunocompromised or oncology patient — pre-radiation clearance, neutropenia precautions, mucositis — A patient is starting chemotherapy or head-and-neck radiation, or is on immunosuppressants.",
      "title": "Immunocompromised or oncology patient — pre-radiation clearance, neutropenia precautions, mucositis",
      "trigger": "A patient is starting chemotherapy or head-and-neck radiation, or is on immunosuppressants",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOMS MRONJ position paper (open) — osteoradionecrosis section applies the same avoid-unnecessary-extraction principle to irradiated bone",
          "source": "AAOMS MRONJ position paper (open) — osteoradionecrosis section applies the same avoid-unnecessary-extraction principle to irradiated bone",
          "url": "https://www.aaoms.org/practice-resources/clinical-resources/medication-related-osteonecrosis-of-the-jaw/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.506 (provider-to-provider consultation)",
          "source": "HIPAA 45 CFR 164.506 (provider-to-provider consultation)"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mcg-009",
      "kind": "clinical",
      "materials": [
        "health history form",
        "panoramic or targeted radiograph",
        "referral letter template",
        "oxygen source location note"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Ask when, where (which jaw/field), total dose, and confirm with oncology records if available before any extraction is scheduled.\n\nWhy: Osteoradionecrosis risk depends on whether the extraction site sits inside the irradiated field and the total dose received.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm radiation history at intake",
          "why": "Osteoradionecrosis risk depends on whether the extraction site sits inside the irradiated field and the total dose received."
        },
        {
          "detail": "Is the planned extraction site inside the irradiated field?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "Yes — inside the field"
            },
            {
              "goto": "s8",
              "id": "o2",
              "label": "No — outside the field"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the planned extraction site inside the irradiated field?"
        },
        {
          "detail": "Consider endodontic treatment or a decoronation approach instead of extraction whenever the tooth can be retained.\n\nWhy: Avoiding extraction in irradiated bone is the single most protective step against osteoradionecrosis.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Exhaust non-surgical options first",
          "why": "Avoiding extraction in irradiated bone is the single most protective step against osteoradionecrosis."
        },
        {
          "detail": "The treating dentist must document the risk discussion and sign off before scheduling; do not delegate this decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off required before proceeding with any extraction in the field.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off required before proceeding with any extraction in the field"
        },
        {
          "detail": "Send a written referral describing the field, dose, and extraction need; request a joint plan before any extraction proceeds.\n\nWhy: Extraction in irradiated bone is generally deferred to a specialist team equipped to manage the healing risk.",
          "id": "s5",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Refer to oral surgery or the radiation oncology team",
          "why": "Extraction in irradiated bone is generally deferred to a specialist team equipped to manage the healing risk."
        },
        {
          "detail": "Record the radiation history, the sign-off, and the referral outcome in the permanent chart.\n\nRecord: Radiation history, field/dose, risk discussion, sign-off, and referral correspondence in the chart",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the referral and risk discussion"
        },
        {
          "detail": "Extraction deferred to specialist coordination",
          "id": "s7",
          "kind": "step",
          "title": "Extraction deferred to specialist coordination"
        },
        {
          "detail": "Follow the practice's routine extraction protocol; radiation history alone does not restrict sites outside the field.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with standard extraction protocol outside the field"
        },
        {
          "detail": "Note in the chart that the extraction site is outside the irradiated field and history is informational only.\n\nRecord: Radiation history noted in chart as informational, no field overlap",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Document radiation history as non-contributory"
        },
        {
          "detail": "Standard extraction completed",
          "id": "s10",
          "kind": "step",
          "title": "Standard extraction completed"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Prior head-and-neck radiation — osteoradionecrosis risk and extraction referral — A patient with a radiation history needs an extraction in the irradiated field.",
      "title": "Prior head-and-neck radiation — osteoradionecrosis risk and extraction referral",
      "trigger": "A patient with a radiation history needs an extraction in the irradiated field",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.510 (personal representatives)",
          "source": "HIPAA 45 CFR 164.510 (personal representatives)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "generic",
          "label": "ADA/ACOG-style patient-consent public consensus framework applied generically to informed consent capacity — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "ADA/ACOG-style patient-consent public consensus framework applied generically to informed consent capacity"
          },
          "source": "ADA/ACOG-style patient-consent public consensus framework applied generically to informed consent capacity — Practice policy — no published authority governs this step."
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mcg-010",
      "kind": "clinical",
      "materials": [
        "capacity screening checklist",
        "surrogate/power-of-attorney documentation form",
        "large-print consent form",
        "caregiver contact log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "caregiver",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note specific observations such as inability to repeat back the plan, disorientation to time/place, or contradictory answers.\n\nWhy: A concrete record of what was observed supports the capacity determination and protects the practice.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Observe and note signs of confusion during the discussion",
          "why": "A concrete record of what was observed supports the capacity determination and protects the practice."
        },
        {
          "detail": "Does the patient appear to have capacity to consent to this specific treatment decision?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "Yes — patient understands and can communicate a choice"
            },
            {
              "goto": "s5",
              "id": "o2",
              "label": "No — patient cannot understand or communicate a choice"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient appear to have capacity to consent to this specific treatment decision?"
        },
        {
          "detail": "Explain the plan in plain language, confirm the patient can restate it, and obtain their signature.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with standard informed consent directly with the patient"
        },
        {
          "detail": "Standard consent obtained from the patient",
          "id": "s4",
          "kind": "step",
          "title": "Standard consent obtained from the patient"
        },
        {
          "detail": "Ask front desk to locate the surrogate/power-of-attorney documentation on file or request it from the caregiver present.\n\nWhy: Consent for a patient lacking capacity must come from a legally authorized representative, not informally from whoever accompanies them.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the legal surrogate or power-of-attorney holder",
          "why": "Consent for a patient lacking capacity must come from a legally authorized representative, not informally from whoever accompanies them."
        },
        {
          "detail": "While identifying the surrogate, note any signs of physical injury inconsistent with the explanation given, caregiver reluctance to let the patient answer or be alone, apparent financial control, or the patient seeming fearful of the caregiver.\n\nWhy: A patient who cannot advocate for themselves and is accompanied by someone claiming decision-making authority is exactly the situation mandated-reporting duties exist to catch — this has to be screened regardless of whether surrogate consent is otherwise straightforward.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Screen for signs of abuse, neglect, or financial exploitation by the accompanying caregiver",
          "why": "A patient who cannot advocate for themselves and is accompanied by someone claiming decision-making authority is exactly the situation mandated-reporting duties exist to catch — this has to be screened regardless of whether surrogate consent is otherwise straightforward."
        },
        {
          "detail": "Are there signs of possible abuse, neglect, or financial exploitation?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-signs",
              "label": "No signs observed"
            },
            {
              "goto": "s12",
              "id": "signs-present",
              "label": "Signs present — file a mandated report"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Are there signs of possible abuse, neglect, or financial exploitation?"
        },
        {
          "detail": "The treating dentist documents and signs the capacity determination before any surrogate-consented treatment begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the capacity determination before treatment proceeds.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the capacity determination before treatment proceeds"
        },
        {
          "detail": "Walk the surrogate/caregiver through the plan, risks, and alternatives; answer questions before requesting their signature.",
          "id": "s9",
          "kind": "step",
          "role": "caregiver",
          "title": "Involve the caregiver in reviewing and confirming the clinical plan"
        },
        {
          "detail": "File the capacity notes, surrogate documentation, and signed consent form in the chart.\n\nRecord: Capacity determination, surrogate identity/documentation, and signed consent in the chart",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the capacity determination and surrogate consent"
        },
        {
          "detail": "Surrogate consent obtained and documented",
          "id": "s11",
          "kind": "step",
          "title": "Surrogate consent obtained and documented"
        },
        {
          "detail": "Contact the state's adult protective services agency (or the mandated-reporting channel required by state law) to report the specific observations; this report is filed independently of whether surrogate consent is otherwise obtained, and does not wait for the capacity/consent process to finish.\n\nWhy: Mandated-reporting duty exists to protect the patient and does not depend on how the treatment-consent question is resolved.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Report suspected abuse, neglect, or exploitation to adult protective services",
          "why": "Mandated-reporting duty exists to protect the patient and does not depend on how the treatment-consent question is resolved."
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Cognitive impairment — capacity assessment, surrogate consent, caregiver involvement in the clinical plan — A patient shows confusion during the treatment discussion, or a caregiver signs on their behalf.",
      "title": "Cognitive impairment — capacity assessment, surrogate consent, caregiver involvement in the clinical plan",
      "trigger": "A patient shows confusion during the treatment discussion, or a caregiver signs on their behalf",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR §164.506 — permits PHI disclosure between providers for treatment consultation (does not prescribe clinical management content)",
          "repaired": {
            "action": "reduce",
            "evidence": "45 CFR 164.506 governs 'Uses and disclosures to carry out treatment, payment, or health care operations' — it authorizes a covered entity to use or disclose PHI for treatment activities, including consultation between health care providers, without requiring patient authorization for that purpose. It contains no clinical-management standards for drug-interaction screening or bleeding-disorder coordination.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.506 (provider-to-provider consultation)",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
            }
          },
          "source": "HIPAA 45 CFR §164.506 (Uses and disclosures to carry out treatment, payment, or health care operations). Scope: supports only the disclosure-permission step in mcg-001 (medical consultation/clearance request routed to the physician, response received, chart closed) — does NOT prescribe how to clinically manage polypharmacy/drug interactions (mcg-012) or a bleeding disorder/hematology coordination plan (mcg-013), which are clinical-guideline matters this section does not address.",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "generic",
          "label": "Generic clinical pharmacology principle that ≥5 concurrent medications raises interaction risk — applied to dental prescribing (local anesthetics, analgesics, antibiotics, sedatives) without a single named public dental-specific standard — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic clinical pharmacology principle that ≥5 concurrent medications raises interaction risk — applied to dental prescribing (local anesthetics, analgesics, antibiotics, sedatives) without a single named public dental-specific standard"
          },
          "source": "Generic clinical pharmacology principle that ≥5 concurrent medications raises interaction risk — applied to dental prescribing (local anesthetics, analgesics, antibiotics, sedatives) without a single named public dental-specific standard — Practice policy — no published authority governs this step."
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "mcg-012",
      "kind": "clinical",
      "materials": [
        "current medication list form",
        "drug-interaction reference (open formulary or public database)",
        "physician contact log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask the patient to list every prescription, over-the-counter drug, and supplement taken currently, including dose and frequency.\n\nWhy: An incomplete list is the most common cause of a missed dental drug interaction.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Collect the complete current medication list",
          "why": "An incomplete list is the most common cause of a missed dental drug interaction."
        },
        {
          "detail": "Does the list include five or more medications, or a high-risk class (anticoagulant, immunosuppressant, bisphosphonate, benzodiazepine, opioid)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "No — low interaction risk"
            },
            {
              "goto": "s6",
              "id": "o2",
              "label": "Yes — screen before prescribing or anesthetizing"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the list include five or more medications, or a high-risk class (anticoagulant, immunosuppressant, bisphosphonate, benzodiazepine, opioid)?"
        },
        {
          "detail": "Follow standard dosing and note the medication list in the chart; no additional screening required.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with routine prescribing precautions"
        },
        {
          "detail": "File the medication list, screening result, and any consult outcome in the permanent chart.\n\nRecord: Medication list, interaction screen result, and any physician consult in the chart",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the medication review and outcome"
        },
        {
          "detail": "Polypharmacy review complete",
          "id": "s5",
          "kind": "step",
          "title": "Polypharmacy review complete"
        },
        {
          "detail": "Check each planned local anesthetic, analgesic, antibiotic, or sedative against the patient's list using an open interaction reference.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Screen planned dental drugs against the current medication list"
        },
        {
          "detail": "Was a clinically significant interaction identified?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "o1",
              "label": "No significant interaction found"
            },
            {
              "goto": "s8",
              "id": "o2",
              "label": "Significant interaction found — contact the prescribing physician"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Was a clinically significant interaction identified?"
        },
        {
          "detail": "Call or send a written consult describing the planned dental drug and the interaction concern; request guidance on an alternative or timing adjustment.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Contact the prescribing physician before proceeding"
        },
        {
          "detail": "The treating dentist documents the physician's response and signs off on the adjusted plan before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the adjusted plan before prescribing or treating.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the adjusted plan before prescribing or treating"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Polypharmacy review and dental drug-interaction screen — A patient lists five or more medications or a high-risk drug class.",
      "title": "Polypharmacy review and dental drug-interaction screen",
      "trigger": "A patient lists five or more medications or a high-risk drug class",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR §164.506 — permits PHI disclosure between providers for treatment consultation (does not prescribe clinical management content)",
          "repaired": {
            "action": "reduce",
            "evidence": "45 CFR 164.506 governs 'Uses and disclosures to carry out treatment, payment, or health care operations' — it authorizes a covered entity to use or disclose PHI for treatment activities, including consultation between health care providers, without requiring patient authorization for that purpose. It contains no clinical-management standards for drug-interaction screening or bleeding-disorder coordination.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.506 (provider-to-provider consultation)",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
            }
          },
          "source": "HIPAA 45 CFR §164.506 (Uses and disclosures to carry out treatment, payment, or health care operations). Scope: supports only the disclosure-permission step in mcg-001 (medical consultation/clearance request routed to the physician, response received, chart closed) — does NOT prescribe how to clinically manage polypharmacy/drug interactions (mcg-012) or a bleeding disorder/hematology coordination plan (mcg-013), which are clinical-guideline matters this section does not address.",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "generic",
          "label": "Generic hemostasis principle applied to dental extraction/surgery in a known bleeding disorder — coordinate with hematology before any invasive procedure; no single named public dental-specific standard identified",
          "source": "Generic hemostasis principle applied to dental extraction/surgery in a known bleeding disorder — coordinate with hematology before any invasive procedure; no single named public dental-specific standard identified"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mcg-013",
      "kind": "clinical",
      "materials": [
        "health history form",
        "local hemostatic agents",
        "hematology referral letter template",
        "post-procedure bleeding instructions sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Ask for the specific diagnosis, treating hematologist, and current factor or antifibrinolytic regimen at intake.\n\nWhy: The management plan differs significantly by disorder type and severity, so a vague history is not enough to plan around.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the bleeding disorder diagnosis and current management",
          "why": "The management plan differs significantly by disorder type and severity, so a vague history is not enough to plan around."
        },
        {
          "detail": "Is the planned procedure invasive (extraction, surgery, deep scaling with expected bleeding)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "No — non-invasive procedure"
            },
            {
              "goto": "s6",
              "id": "o2",
              "label": "Yes — invasive procedure requires hematology coordination"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the planned procedure invasive (extraction, surgery, deep scaling with expected bleeding)?"
        },
        {
          "detail": "Document the disorder as informational and proceed with standard non-invasive care precautions.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with routine care and note the bleeding disorder in the chart"
        },
        {
          "detail": "File the diagnosis, consult correspondence, hemostasis plan, and follow-up outcome in the chart.\n\nRecord: Diagnosis, hematology consult, hemostasis plan, and follow-up outcome in the chart",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the coordination and outcome"
        },
        {
          "detail": "Bleeding disorder coordination complete",
          "id": "s5",
          "kind": "step",
          "title": "Bleeding disorder coordination complete"
        },
        {
          "detail": "Send a written consult describing the planned procedure and request a factor replacement or antifibrinolytic plan.",
          "id": "s6",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Contact the treating hematologist before the procedure"
        },
        {
          "detail": "The treating dentist documents the hematologist's plan and signs off before scheduling the procedure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the hemostasis plan before proceeding.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the hemostasis plan before proceeding"
        },
        {
          "detail": "Use local hemostatic agents and atraumatic technique as coordinated with hematology's plan.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Apply local hemostatic measures during the procedure"
        },
        {
          "detail": "Give the patient a sheet describing normal versus concerning bleeding and when to call the office or seek emergency care.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Provide written post-procedure bleeding instructions"
        },
        {
          "detail": "Call the patient within 24 hours to confirm bleeding has resolved as expected.",
          "id": "s10",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 86400,
          "title": "Follow-up check within 24 hours"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Bleeding disorder — hematology coordination and factor or antifibrinolytic plan — A patient reports hemophilia, von Willebrand disease or an unexplained bleeding history.",
      "title": "Bleeding disorder — hematology coordination and factor or antifibrinolytic plan",
      "trigger": "A patient reports hemophilia, von Willebrand disease or an unexplained bleeding history",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.506 (provider-to-provider consultation) — class floor citation, applicable to medication-assisted treatment prescriber coordination",
          "source": "HIPAA 45 CFR 164.506 (provider-to-provider consultation) — class floor citation, applicable to medication-assisted treatment prescriber coordination",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "generic",
          "label": "Generic prescribing-safety principle applied to dental analgesia in a patient with substance use disorder or on medication-assisted treatment — prefer non-opioid pain management and coordinate before prescribing controlled substances; no single named public dental-specific standard identified",
          "source": "Generic prescribing-safety principle applied to dental analgesia in a patient with substance use disorder or on medication-assisted treatment — prefer non-opioid pain management and coordinate before prescribing controlled substances; no single named public dental-specific standard identified"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "mcg-015",
      "kind": "clinical",
      "materials": [
        "health history form with confidential disclosure option",
        "non-opioid pain management protocol sheet",
        "medication-assisted treatment provider contact log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Move the conversation away from the open front desk area; use neutral, clinical language and thank the patient for disclosing.\n\nWhy: A private, non-judgmental intake increases the chance of an accurate history, which is what keeps prescribing decisions safe.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the disclosure privately and without judgment",
          "why": "A private, non-judgmental intake increases the chance of an accurate history, which is what keeps prescribing decisions safe."
        },
        {
          "detail": "Ask specifically whether the patient takes a medication-assisted treatment prescription and who prescribes it.\n\nWhy: Some medication-assisted treatments interact with commonly used dental sedatives and analgesics.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm whether the patient is on medication-assisted treatment",
          "why": "Some medication-assisted treatments interact with commonly used dental sedatives and analgesics."
        },
        {
          "detail": "Is a procedure requiring pain management or sedation planned?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "o1",
              "label": "No — routine visit, no analgesia/sedation planned"
            },
            {
              "goto": "s7",
              "id": "o2",
              "label": "Yes — pain management or sedation planning needed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a procedure requiring pain management or sedation planned?"
        },
        {
          "detail": "Complete the visit with standard care; document the disclosure for future reference.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with routine care"
        },
        {
          "detail": "File the disclosure, medication-assisted treatment status, and final pain management plan in the chart with standard confidentiality.\n\nRecord: Disclosure, medication-assisted treatment status, and pain management plan in the chart",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the disclosure and plan"
        },
        {
          "detail": "Care plan completed with stigma-free coordination",
          "id": "s6",
          "kind": "step",
          "title": "Care plan completed with stigma-free coordination"
        },
        {
          "detail": "Use the practice's non-opioid protocol (e.g., scheduled non-opioid analgesics, local anesthesia optimization) as the first-line plan.\n\nWhy: Avoiding opioid prescribing where possible reduces relapse risk and interaction concerns with medication-assisted treatment.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Default to a non-opioid pain management plan",
          "why": "Avoiding opioid prescribing where possible reduces relapse risk and interaction concerns with medication-assisted treatment."
        },
        {
          "detail": "Is the patient on medication-assisted treatment that could interact with the planned sedative or analgesic?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "o1",
              "label": "No interaction concern"
            },
            {
              "goto": "s10",
              "id": "o2",
              "label": "Interaction concern — coordinate with the prescriber"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient on medication-assisted treatment that could interact with the planned sedative or analgesic?"
        },
        {
          "detail": "The treating dentist documents the plan and any prescriber consult, then signs off before treatment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the pain management plan before proceeding.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the pain management plan before proceeding"
        },
        {
          "detail": "Call or send a written consult describing the planned dental drug and request guidance on timing or alternatives.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Contact the medication-assisted treatment prescriber before finalizing the plan"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Substance use disorder — anesthesia, prescribing and stigma-free care considerations — A patient discloses current or past substance use or is on medication-assisted treatment.",
      "title": "Substance use disorder — anesthesia, prescribing and stigma-free care considerations",
      "trigger": "A patient discloses current or past substance use or is on medication-assisted treatment",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.506 (provider-to-provider consultation) — class floor citation, applicable to dialysis center care coordination",
          "source": "HIPAA 45 CFR 164.506 (provider-to-provider consultation) — class floor citation, applicable to dialysis center care coordination",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "generic",
          "label": "Generic dialysis-scheduling principle applied to dental care — schedule treatment on the non-dialysis day, avoid the fistula/graft arm for blood pressure and injections, and monitor for bleeding given anticoagulation used during dialysis; no single named public dental-specific standard identified",
          "source": "Generic dialysis-scheduling principle applied to dental care — schedule treatment on the non-dialysis day, avoid the fistula/graft arm for blood pressure and injections, and monitor for bleeding given anticoagulation used during dialysis; no single named public dental-specific standard identified"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "mcg-016",
      "kind": "clinical",
      "materials": [
        "dialysis schedule intake form",
        "arteriovenous fistula/graft arm identification note",
        "blood pressure cuff placement reminder card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "scheduler",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask which days the patient dialyzes and which arm holds the fistula or graft; record both clearly.\n\nWhy: Scheduling on the wrong day or using the fistula arm for a blood pressure cuff can cause serious complications.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Confirm the dialysis schedule and which arm has the fistula or graft",
          "why": "Scheduling on the wrong day or using the fistula arm for a blood pressure cuff can cause serious complications."
        },
        {
          "detail": "Book the appointment for the day following a dialysis session, when heparin from the session has cleared and the patient feels best.\n\nWhy: Scheduling on the dialysis day itself risks residual anticoagulant effect and patient fatigue; scheduling right before dialysis leaves accumulated toxins and fluid overload unaddressed.",
          "id": "s2",
          "kind": "step",
          "role": "scheduler",
          "title": "Schedule the appointment for the day after dialysis",
          "why": "Scheduling on the dialysis day itself risks residual anticoagulant effect and patient fatigue; scheduling right before dialysis leaves accumulated toxins and fluid overload unaddressed."
        },
        {
          "detail": "Mark the chart and place a visible reminder card so no one uses that arm for blood pressure or injections.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Flag the fistula/graft arm in the chart and at chairside"
        },
        {
          "detail": "Confirm which arm is clear before placing the cuff; never compress the fistula or graft site.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Take blood pressure only on the non-fistula arm"
        },
        {
          "detail": "Is an invasive procedure planned (extraction, surgery, deep scaling)?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "o1",
              "label": "No — non-invasive procedure"
            },
            {
              "goto": "s9",
              "id": "o2",
              "label": "Yes — invasive procedure, extra bleeding monitoring needed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is an invasive procedure planned (extraction, surgery, deep scaling)?"
        },
        {
          "detail": "Complete the visit with standard non-invasive care, keeping fistula-arm precautions in place throughout.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Proceed with routine care using standard precautions"
        },
        {
          "detail": "File the dialysis schedule, fistula arm location, and precautions taken in the chart for future visits.\n\nRecord: Dialysis schedule, fistula arm, and precautions taken noted in chart",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Document dialysis schedule and precautions taken"
        },
        {
          "detail": "Dialysis patient visit completed safely",
          "id": "s8",
          "kind": "step",
          "title": "Dialysis patient visit completed safely"
        },
        {
          "detail": "The treating dentist documents the dialysis timing, anticoagulation risk, and signs off before proceeding with the invasive procedure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the invasive procedure plan given anticoagulation risk.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the invasive procedure plan given anticoagulation risk"
        },
        {
          "detail": "Watch the site closely after the procedure and apply local hemostatic measures if bleeding continues beyond the expected time.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Monitor for prolonged bleeding and apply local hemostasis as needed"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Renal dialysis patient scheduling and precautions — A patient reports hemodialysis.",
      "title": "Renal dialysis patient scheduling and precautions",
      "trigger": "A patient reports hemodialysis",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "No applicable authority — the AHA infective-endocarditis-prophylaxis statement addresses antibiotic premedication for cardiac patients and has no bearing on chair weight ratings or bariatric accommodation — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No applicable authority — the AHA infective-endocarditis-prophylaxis statement addresses antibiotic premedication for cardiac patients and has no bearing on chair weight ratings or bariatric accommodation — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The AHA statement text itself: prophylaxis guidance is 'reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis' and for 'dental procedures that involve manipulation of gingival tissue' — entirely about antibiotic premedication, with no mention of patient weight, chair capacity, or bariatric equipment anywhere.",
            "ticket": "PROT-017",
            "was": {
              "source": "Taxonomy class floor — AHA infective endocarditis prophylaxis statement (open)",
              "url": null
            }
          },
          "source": "No applicable authority — the AHA infective-endocarditis-prophylaxis statement addresses antibiotic premedication for cardiac patients and has no bearing on chair weight ratings or bariatric accommodation — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "No dental-specific regulatory or ADA/AAOS authority located for chair weight-rating/bariatric accommodation — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No dental-specific regulatory or ADA/AAOS authority located for chair weight-rating/bariatric accommodation — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched 'dental chair weight rating bariatric patient accommodation ADA guideline.' The only ADA/AAOS guidance retrievable on prosthetic-joint patients concerns antibiotic prophylaxis before dental procedures -- confirmed by the audit to have nothing to do with bariatric accommodation. Independent search for a bariatric-accommodation authority found only industry/vendor commentary noting 'no federal or statewide laws explicitly prohibit dentists from refusing obese patients due to office capacity constraints' -- i.e., no governing authority exists for this scenario, only manufacturer chair ratings and general ADA-Title-III nondiscrimination principles too broad to cite as the specific floor.",
            "ticket": "PROT-017",
            "was": {
              "source": "Taxonomy class floor — ADA/AAOS prosthetic joint guidance (open)",
              "url": null
            }
          },
          "source": "No dental-specific regulatory or ADA/AAOS authority located for chair weight-rating/bariatric accommodation — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Clinical accommodation guidance for bariatric dental-chair weight limits and breastfeeding-patient drug/anesthetic/radiograph selection — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "Re-read 45 CFR 164.506 directly: it permits (via 'may', not 'shall') a covered entity to use or disclose PHI for treatment/payment/operations, and never addresses equipment weight ratings, bariatric accommodation, or medication/anesthetic/radiograph safety during lactation. mcg-017 (chair weight rating) and mcg-018 (breastfeeding drug/anesthetic/radiograph guidance) are clinical-safety questions with no PHI-disclosure component at all, so no HIPAA disclosure provision — permissive or otherwise — can carry either claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "45 CFR 164.506 — Uses and disclosures to carry out treatment, payment, or health care operations",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.506"
            }
          },
          "source": "No provision of HIPAA (45 CFR 164.506 or elsewhere) addresses chair weight ratings, bariatric accommodation, or breastfeeding-safe drug/anesthetic/radiograph selection — these are clinical-safety and equipment-specification questions, not PHI-disclosure questions, and no authority in scope governs them — generic functional equivalent"
        },
        {
          "kind": "regulation",
          "label": "ADA Americans with Disabilities Act Title III accessibility guidance for medical/dental offices (public)",
          "source": "ADA Americans with Disabilities Act Title III accessibility guidance for medical/dental offices (public)",
          "url": "https://www.ada.gov/resources/dentists-and-dental-clinics/"
        },
        {
          "kind": "generic",
          "label": "Chair weight rating itself is manufacturer-specific and not a public standard — this protocol treats 'confirm the placard, do not guess' as the generic, brand-neutral operating rule",
          "source": "Chair weight rating itself is manufacturer-specific and not a public standard — this protocol treats 'confirm the placard, do not guess' as the generic, brand-neutral operating rule"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mcg-017",
      "kind": "clinical",
      "materials": [
        "chair manufacturer weight-rating placard or manual",
        "bariatric-rated dental chair or transfer bench (if stocked)",
        "wide/reinforced blood-pressure cuff",
        "extra-long instrument set (periodontal probe, retractors) for increased soft-tissue depth",
        "gait belt or transfer aid",
        "seating comfort wedge/positioning cushions"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager",
        "dentist",
        "front-desk",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "When a patient volunteers a weight, mobility, or size concern during scheduling, intake, or at check-in, note it discreetly in the chart as a scheduling/accommodation flag — never as a visible or spoken label in the reception area.\n\nWhy: Handling this early and privately avoids both an unsafe last-minute chairside surprise and any embarrassment to the patient.\n\nRecord: accommodation flag added to patient chart (no numeric weight required at this stage)",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag possible capacity concern at scheduling or check-in",
          "why": "Handling this early and privately avoids both an unsafe last-minute chairside surprise and any embarrassment to the patient."
        },
        {
          "detail": "Locate the manufacturer's weight-rating placard on the chair base or the equipment manual on file; do not rely on memory or a generic industry number, since ratings vary by model and by whether the chair is in a raised/reclined position.\n\nWhy: Operating a chair above its rated capacity is an equipment-failure and patient-injury risk; the rating is equipment-specific, so guessing is the failure mode this step exists to prevent.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "chair manufacturer weight-rating placard or manual"
          ],
          "role": "office-manager",
          "title": "Confirm the actual chair weight rating from the manufacturer placard or manual",
          "why": "Operating a chair above its rated capacity is an equipment-failure and patient-injury risk; the rating is equipment-specific, so guessing is the failure mode this step exists to prevent."
        },
        {
          "detail": "The treating dentist personally confirms it is clinically appropriate to proceed with treatment for this patient today, before the equipment-capacity or transfer-safety decision is made — this determination is not delegated to non-clinical staff.\n\nWhy: The protocol requires licensed clinical review; that review has to actually happen at a point in the workflow before equipment logistics are decided, not be implied by the office-manager and consent gates alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms clinical readiness to treat before capacity/equipment routing.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms clinical readiness to treat before capacity/equipment routing",
          "why": "The protocol requires licensed clinical review; that review has to actually happen at a point in the workflow before equipment logistics are decided, not be implied by the office-manager and consent gates alone."
        },
        {
          "detail": "Does the patient's estimated weight fall within the chair's rated capacity?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "within-rating",
              "label": "Within rating — proceed in the assigned operatory with standard positioning"
            },
            {
              "goto": "s7",
              "id": "at-or-over-rating",
              "label": "At or over rating, or uncertain — do not seat the patient in this chair"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the patient's estimated weight fall within the chair's rated capacity?"
        },
        {
          "detail": "Seat normally, use the wide/reinforced blood-pressure cuff if the standard cuff would be inaccurate, and offer positioning cushions for comfort. Proceed to the visit.\n\nWhy: A too-small BP cuff overestimates blood pressure, which can trigger an unnecessary treatment deferral or an unrecognized true reading — either error affects care.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "wide/reinforced blood-pressure cuff",
            "seating comfort wedge/positioning cushions"
          ],
          "role": "assistant",
          "title": "Use standard positioning with a wide cuff and comfort supports as needed",
          "why": "A too-small BP cuff overestimates blood pressure, which can trigger an unnecessary treatment deferral or an unrecognized true reading — either error affects care."
        },
        {
          "detail": "Visit completed safely with the correct equipment",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Visit completed safely with the correct equipment"
        },
        {
          "detail": "Check whether the practice has a bariatric-rated chair or reinforced operatory available today. If yes, plan the room change. If no equipment is available on site, prepare to reschedule to a location or day when it is, or to refer to a practice/facility with appropriate equipment.\n\nWhy: The goal is safe accommodation, not turning the patient away by default — many practices can serve the patient with a room swap rather than a referral.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify a bariatric-rated chair, alternate operatory, or transfer plan",
          "why": "The goal is safe accommodation, not turning the patient away by default — many practices can serve the patient with a room swap rather than a referral."
        },
        {
          "detail": "Can this visit be safely accommodated on site today or by rescheduling into the right room?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "reschedule-onsite",
              "label": "Reschedule into the bariatric-capable operatory or bring in a rated chair/transfer bench"
            },
            {
              "goto": "s13",
              "id": "refer-out",
              "label": "No suitable equipment available — refer to a practice or facility equipped for the patient's needs"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Can this visit be safely accommodated on site today or by rescheduling into the right room?"
        },
        {
          "detail": "Book the visit into the bariatric-capable operatory (or arrange the rated equipment), and add extra chair time for transfer and positioning.\n\nWhy: Rushing a transfer to stay on the day's schedule is how falls and strain injuries happen.\n\nRecord: appointment rebooked with room and extra-time notation",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Hand off to scheduling to book the correct operatory and appointment length",
          "why": "Rushing a transfer to stay on the day's schedule is how falls and strain injuries happen."
        },
        {
          "detail": "Before using a gait belt, transfer bench, or hands-on assistance, explain the process to the patient and get their verbal go-ahead; ask whether they prefer to self-transfer or be assisted, and how many staff they'd like present.\n\nWhy: A physical transfer touches the patient's body and dignity directly — proceeding without explicit agreement is both a safety and a consent problem, independent of any clinical decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient consent and readiness before physical transfer assistance.",
            "type": "safety"
          },
          "id": "s10",
          "kind": "gate",
          "role": "assistant",
          "title": "Confirm patient consent and readiness before physical transfer assistance",
          "why": "A physical transfer touches the patient's body and dignity directly — proceeding without explicit agreement is both a safety and a consent problem, independent of any clinical decision."
        },
        {
          "detail": "Use the gait belt/transfer aid and at least two staff for hands-on assistance if agreed; use the bariatric-rated chair or bench, wide BP cuff, and comfort supports.\n\nWhy: Two-person assist reduces strain injury risk to both patient and staff during a transfer.",
          "id": "s11",
          "kind": "step",
          "materials": [
            "gait belt or transfer aid",
            "bariatric-rated dental chair or transfer bench (if stocked)",
            "wide/reinforced blood-pressure cuff"
          ],
          "role": "assistant",
          "title": "Perform the transfer and position the patient using the rated equipment",
          "why": "Two-person assist reduces strain injury risk to both patient and staff during a transfer."
        },
        {
          "detail": "Note in the chart which equipment/operatory was used, how the transfer went, and log any near-fall, strain, or equipment-limit event on an incident report even if no injury occurred.\n\nWhy: A documented near-miss lets the practice fix an equipment or process gap before an actual injury happens.\n\nRecord: chart note (equipment used, transfer method) and incident report if applicable",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Document the accommodation used and any incident",
          "why": "A documented near-miss lets the practice fix an equipment or process gap before an actual injury happens."
        },
        {
          "detail": "Identify a nearby practice or hospital dental clinic known to have bariatric-rated equipment, and prepare records transfer per standard authorization so the receiving office isn't starting cold.\n\nWhy: A referral without records forces the patient to repeat their history and delays care.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare a warm referral to an appropriately equipped practice or facility",
          "why": "A referral without records forces the patient to repeat their history and delays care."
        },
        {
          "detail": "Because declining or rerouting a booked patient has both patient-experience and business consequences, the office manager or practice owner confirms the decision and reviews whether an equipment purchase would prevent repeat referrals.\n\nWhy: This is a business and access-to-care decision, not a purely clinical one, so it gets a named non-clinical sign-off before the patient is turned away.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner/office-manager sign-off before turning away a scheduled patient.",
            "role": "office manager or practice owner",
            "type": "licensed"
          },
          "id": "s14",
          "kind": "gate",
          "role": "office-manager",
          "title": "Owner/office-manager sign-off before turning away a scheduled patient",
          "why": "This is a business and access-to-care decision, not a purely clinical one, so it gets a named non-clinical sign-off before the patient is turned away."
        },
        {
          "detail": "Front desk contacts the patient with the referral, offers to help schedule at the receiving location, and confirms records were sent.\n\nRecord: referral sent, records-release documented",
          "id": "s15",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand the patient's records and referral information to the front desk for outreach"
        },
        {
          "detail": "Patient referred to an appropriately equipped location",
          "id": "s16",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient referred to an appropriately equipped location"
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Patient exceeds the dental chair weight rating or needs bariatric accommodation — A patient's weight approaches or exceeds the chair's rated capacity.",
      "title": "Patient exceeds the dental chair weight rating or needs bariatric accommodation",
      "trigger": "A patient's weight approaches or exceeds the chair's rated capacity",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Taxonomy class floor — ADA/ACOG pregnancy oral health consensus (open)",
          "source": "Taxonomy class floor — ADA/ACOG pregnancy oral health consensus (open)"
        },
        {
          "kind": "regulation",
          "label": "Clinical accommodation guidance for bariatric dental-chair weight limits and breastfeeding-patient drug/anesthetic/radiograph selection — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "Re-read 45 CFR 164.506 directly: it permits (via 'may', not 'shall') a covered entity to use or disclose PHI for treatment/payment/operations, and never addresses equipment weight ratings, bariatric accommodation, or medication/anesthetic/radiograph safety during lactation. mcg-017 (chair weight rating) and mcg-018 (breastfeeding drug/anesthetic/radiograph guidance) are clinical-safety questions with no PHI-disclosure component at all, so no HIPAA disclosure provision — permissive or otherwise — can carry either claim.",
            "ticket": "PROT-017",
            "was": {
              "source": "45 CFR 164.506 — Uses and disclosures to carry out treatment, payment, or health care operations",
              "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.506"
            }
          },
          "source": "No provision of HIPAA (45 CFR 164.506 or elsewhere) addresses chair weight ratings, bariatric accommodation, or breastfeeding-safe drug/anesthetic/radiograph selection — these are clinical-safety and equipment-specification questions, not PHI-disclosure questions, and no authority in scope governs them — generic functional equivalent"
        },
        {
          "kind": "open_standard",
          "label": "ADA 2024 updated guidance (JADA, Feb 1 2024): lead aprons and thyroid collars are NOT necessary for dental radiographs, for any patient regardless of age or health status (including pregnancy/lactation) — superseding the older 'use lead shielding' position",
          "repaired": {
            "action": "replace",
            "evidence": "The ADA's expert panel determined lead aprons and thyroid collars are not necessary to shield patients from radiation exposure, and these recommendations apply to all patients, regardless of age or health status (like pregnancy)... released February 1, 2024.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA guidance: dental radiographs use lead shielding and are considered safe during lactation with standard protective measures",
              "url": "https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/pregnancy"
            }
          },
          "source": "ADA Council on Scientific Affairs expert panel guidance, published JADA, Feb. 1, 2024",
          "url": "https://www.ada.org/about/press-releases/ada-releases-updated-recommendations-to-enhance-radiography-safety-in-dentistry"
        },
        {
          "kind": "public_domain",
          "label": "Local anesthetics (e.g. lidocaine) and most routine dental antibiotics/analgesics are compatible with breastfeeding per NIH LactMed, a US National Library of Medicine public database",
          "source": "Local anesthetics (e.g. lidocaine) and most routine dental antibiotics/analgesics are compatible with breastfeeding per NIH LactMed, a US National Library of Medicine public database",
          "url": "https://www.ncbi.nlm.nih.gov/books/NBK501922/"
        }
      ],
      "class": "medically-complex-geriatric-care",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "mcg-018",
      "kind": "clinical",
      "materials": [
        "current health history form noting breastfeeding status",
        "lead apron and thyroid collar for radiographs",
        "reference source for lactation-safety of medications (e.g. a maintained public lactation drug database)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "At intake or update, ask directly whether the patient is currently breastfeeding and note it on the health history form so every treating provider sees the flag.\n\nWhy: Anesthetic, prescription, and imaging decisions all change based on this single fact, so it has to be visible before treatment planning, not discovered mid-procedure.\n\nRecord: breastfeeding status recorded on health history",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm and record breastfeeding status on the health history",
          "why": "Anesthetic, prescription, and imaging decisions all change based on this single fact, so it has to be visible before treatment planning, not discovered mid-procedure."
        },
        {
          "detail": "What does today's visit require — imaging, anesthesia, a prescription, or a combination?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "imaging-only",
              "label": "Radiographs only"
            },
            {
              "goto": "s5",
              "id": "anesthesia-or-rx",
              "label": "Local anesthesia and/or a prescription is needed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "What does today's visit require — imaging, anesthesia, a prescription, or a combination?"
        },
        {
          "detail": "Use the lead apron and thyroid collar as for any patient; dental radiographs do not require pumping-and-discarding milk or any interruption to breastfeeding.\n\nWhy: Radiographs are localized and shielded, so the radiation exposure reaching breast tissue or milk is not a lactation-safety concern per public ADA guidance.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "lead apron and thyroid collar for radiographs"
          ],
          "role": "hygienist",
          "title": "Take radiographs with standard lead shielding as normal",
          "why": "Radiographs are localized and shielded, so the radiation exposure reaching breast tissue or milk is not a lactation-safety concern per public ADA guidance."
        },
        {
          "detail": "Imaging completed, no lactation impact",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Imaging completed, no lactation impact"
        },
        {
          "detail": "For the specific local anesthetic, analgesic, or antibiotic planned, look it up in the practice's chosen lactation drug reference (e.g. the public NIH LactMed database) rather than relying on memory, since safety varies by specific drug and dose.\n\nWhy: Most routine dental drugs are compatible with breastfeeding, but a few (e.g. certain long-acting sedatives or specific antibiotics) are not — checking the specific drug avoids both unnecessary treatment withholding and an unsafe prescription.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "reference source for lactation-safety of medications (e.g. a maintained public lactation drug database)"
          ],
          "role": "dentist",
          "title": "Check each planned drug against a maintained lactation-safety reference",
          "why": "Most routine dental drugs are compatible with breastfeeding, but a few (e.g. certain long-acting sedatives or specific antibiotics) are not — checking the specific drug avoids both unnecessary treatment withholding and an unsafe prescription."
        },
        {
          "detail": "Is the planned drug and dose confirmed compatible with breastfeeding?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "compatible",
              "label": "Confirmed compatible at the planned dose — proceed"
            },
            {
              "goto": "s10",
              "id": "uncertain-or-not-compatible",
              "label": "Uncertain, or the reference flags a concern — choose an alternative or consult"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the planned drug and dose confirmed compatible with breastfeeding?"
        },
        {
          "detail": "Proceed with treatment and give the patient plain-language guidance: for routine local anesthetics and most dental antibiotics/analgesics, no pumping-and-discarding is needed; continue nursing as usual unless a specific drug's guidance says otherwise.\n\nWhy: Patients are frequently told incorrectly to 'pump and dump' after routine dental care, which discourages needed treatment — giving accurate guidance removes that barrier.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Administer anesthesia and/or send the prescription, with plain-language guidance to the patient",
          "why": "Patients are frequently told incorrectly to 'pump and dump' after routine dental care, which discourages needed treatment — giving accurate guidance removes that barrier."
        },
        {
          "detail": "Note in the chart which drug and dose were used, the lactation-safety reference checked, and any physician/pediatrician consult and its outcome.\n\nRecord: chart note: drug/dose, reference checked, consult outcome if any",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the medication/imaging decision and any consult"
        },
        {
          "detail": "Treatment completed with lactation-safe medication choice documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Treatment completed with lactation-safe medication choice documented"
        },
        {
          "detail": "Where a same-purpose alternative drug with a clearer safety profile exists, use it. Where no good alternative exists, contact the patient's physician or the baby's pediatrician before prescribing.\n\nWhy: A same-class substitute usually resolves the concern without delaying care; a consult is reserved for cases where no substitute is available.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Substitute a known-compatible alternative or consult the patient's physician/pediatrician",
          "why": "A same-class substitute usually resolves the concern without delaying care; a consult is reserved for cases where no substitute is available."
        },
        {
          "detail": "The treating dentist reviews the final drug choice and consult outcome (if any) and confirms it before the medication is given or the prescription is sent.\n\nWhy: A medication decision made under uncertainty needs an explicit licensed confirmation before it reaches the patient, not an assumption that the substitution was automatically fine.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off before administering or prescribing the substituted or consulted-on medication.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off before administering or prescribing the substituted or consulted-on medication",
          "why": "A medication decision made under uncertainty needs an explicit licensed confirmation before it reaches the patient, not an assumption that the substitution was automatically fine."
        }
      ],
      "subclass": "medically-complex-and-geriatric-care",
      "summary": "Breastfeeding patient: drug, anesthetic and radiograph guidance — A patient reports she is nursing before anesthesia, a prescription or imaging.",
      "title": "Breastfeeding patient: drug, anesthetic and radiograph guidance",
      "trigger": "A patient reports she is nursing before anesthesia, a prescription or imaging",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 severity triage rule (any score ≥8/10 → 911 first) and §7.2 kit list",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 severity triage rule (any score ≥8/10 → 911 first) and §7.2 kit list"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "mep-001",
      "kind": "clinical",
      "materials": [
        "emergency kit",
        "oxygen tank + regulator + masks",
        "AED",
        "blood pressure cuff and stethoscope",
        "pulse oximeter",
        "phone with outside line"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Any team member who sees a patient, visitor or coworker become acutely unwell STOPS what they are doing. If the person is unresponsive, not breathing normally, or in obvious severe distress, call 911 immediately — before finishing any other task.\n\nWhy: Per DOCS/TECHNICAL_PROTOCOLS.md §7.1, any severity ≥8/10 event calls 911 before any other action; delay to 'finish the step first' is the most common preventable error in office emergencies.",
          "gate": {
            "ack": "I confirm I have completed this step as written: STOP — recognize a medical emergency and call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "STOP — recognize a medical emergency and call 911 first",
          "why": "Per DOCS/TECHNICAL_PROTOCOLS.md §7.1, any severity ≥8/10 event calls 911 before any other action; delay to 'finish the step first' is the most common preventable error in office emergencies."
        },
        {
          "detail": "The dentist (the licensed professional on site) confirms they are directing the response, assigning roles and authorizing any intervention the team performs — this is not paperwork, it is who is in charge of clinical decisions for the next several minutes.\n\nWhy: A licensed professional must own clinical decision-making during an emergency response, not just execute steps by rote.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Attending dentist confirms and directs the response.",
            "role": "attending dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Attending dentist confirms and directs the response",
          "why": "A licensed professional must own clinical decision-making during an emergency response, not just execute steps by rote."
        },
        {
          "detail": "Announce the emergency using the office's internal alert phrase (loud, clear, once) so nearby staff converge. The nearest clinical team member stays at the patient's side continuously.\n\nWhy: A single unambiguous alert prevents wasted seconds re-explaining what is happening room to room.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Call out the internal alert and stay with the patient",
          "why": "A single unambiguous alert prevents wasted seconds re-explaining what is happening room to room."
        },
        {
          "detail": "One person is assigned to call 911; everyone else has a job.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "front-desk-calls",
              "label": "Front desk places the call (dentist and assistant stay clinical)"
            },
            {
              "goto": "s5",
              "id": "nearest-staff-calls",
              "label": "Nearest available staff member calls if front desk is not reachable"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "Who places the 911 call?"
        },
        {
          "detail": "State: office address and suite number, nearest cross street, callback number, patient's condition (conscious/unconscious, breathing/not breathing), and any known allergy or condition. Do not hang up until the dispatcher releases the line.\n\nWhy: Dispatchers often stay on the line to give pre-arrival instructions (e.g. CPR coaching); hanging up early loses that support.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Call 911 and give the dispatcher the essentials",
          "why": "Dispatchers often stay on the line to give pre-arrival instructions (e.g. CPR coaching); hanging up early loses that support."
        },
        {
          "detail": "A team member not directly needed at chairside is sent to prop open the entrance, clear the path, and flag down the ambulance so EMS does not lose time finding the room.\n\nWhy: Seconds spent searching for the right suite in a multi-tenant building are seconds EMS is not treating the patient.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Assign a team member to meet EMS at the door",
          "why": "Seconds spent searching for the right suite in a multi-tenant building are seconds EMS is not treating the patient."
        },
        {
          "detail": "Retrieve the emergency kit, O2 tank/regulator/masks, and AED from their fixed storage location and bring them to the patient's side, even if not yet used.\n\nWhy: Having equipment at hand before it is needed avoids a second delay if the patient deteriorates further.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Bring the emergency kit, oxygen and AED to the room",
          "why": "Having equipment at hand before it is needed avoids a second delay if the patient deteriorates further."
        },
        {
          "detail": "Position appropriately for the presentation (e.g. supine with legs elevated for suspected fainting, upright for breathing difficulty) and, if the patient is stable enough, take blood pressure, pulse, and oxygen saturation.\n\nWhy: Vitals taken now give EMS a baseline trend on arrival instead of a single snapshot.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Position the patient and take vitals if safe to do so",
          "why": "Vitals taken now give EMS a baseline trend on arrival instead of a single snapshot."
        },
        {
          "detail": "Hand EMS a verbal summary: what happened, onset time, vitals trend, medications/interventions given, and any known allergies or medical history from the chart.\n\nWhy: A structured handoff prevents EMS from repeating assessment steps already done.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Brief EMS on arrival",
          "why": "A structured handoff prevents EMS from repeating assessment steps already done."
        },
        {
          "detail": "Record onset time, presenting signs, interventions performed, vitals over time, 911 call time, EMS arrival time, and disposition (transported / refused transport / resolved on site) in the chart.\n\nRecord: Chart note: timeline, interventions, vitals, EMS disposition.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the event in the patient chart"
        },
        {
          "detail": "Event closed — proceed to post-event debrief protocol",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Event closed — proceed to post-event debrief protocol"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Universal first response — stop, position, call 911, assign roles, get the kit and AED — Any patient, visitor or team member becomes acutely unwell anywhere in the office.",
      "title": "Universal first response — stop, position, call 911, assign roles, get the kit and AED",
      "trigger": "Any patient, visitor or team member becomes acutely unwell anywhere in the office",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support guidelines",
          "source": "AHA Basic Life Support guidelines"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "url": "https://www.ada.org/resources/ada-library/oral-health-topics/medical-emergencies-in-the-dental-office"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: vasovagal syncope — lay flat, legs up, O2, ammonia inhalant, monitor",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: vasovagal syncope — lay flat, legs up, O2, ammonia inhalant, monitor"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "mep-002",
      "kind": "clinical",
      "materials": [
        "ammonia inhalants",
        "oxygen tank + regulator + masks",
        "blood pressure cuff and stethoscope",
        "pulse oximeter"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the patient is unresponsive and not breathing normally, treat as cardiac arrest and call 911 immediately (see mep-004). If they are pale, sweaty, briefly lost consciousness and are now breathing normally with a pulse, proceed as vasovagal syncope.\n\nWhy: Syncope and cardiac arrest can look similar in the first seconds; breathing and pulse check separates them before any treatment begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Recognize syncope and confirm this is not a more severe event.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Recognize syncope and confirm this is not a more severe event",
          "why": "Syncope and cardiac arrest can look similar in the first seconds; breathing and pulse check separates them before any treatment begins."
        },
        {
          "detail": "The treating dentist or hygienist confirms the presentation is consistent with vasovagal syncope (not a more severe event) and authorizes positioning, oxygen and ammonia inhalant use.\n\nWhy: The clinical call that this is syncope rather than a more dangerous event must be made by the licensed professional before treatment proceeds.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating clinician confirms this is syncope and authorizes treatment.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating clinician confirms this is syncope and authorizes treatment",
          "why": "The clinical call that this is syncope rather than a more dangerous event must be made by the licensed professional before treatment proceeds."
        },
        {
          "detail": "Recline the chair fully, elevate the legs above heart level (Trendelenburg-like position), and loosen any tight clothing at the neck.\n\nWhy: Restoring venous return to the brain is the direct treatment for a vasovagal episode.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Stop the procedure and lay the patient flat with legs elevated",
          "why": "Restoring venous return to the brain is the direct treatment for a vasovagal episode."
        },
        {
          "detail": "Check the mouth is clear of instruments or debris and apply oxygen by nasal cannula or mask.\n\nWhy: An unconscious patient can obstruct their own airway; clearing it precedes any other intervention.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the airway is clear and give oxygen",
          "why": "An unconscious patient can obstruct their own airway; clearing it precedes any other intervention."
        },
        {
          "detail": "Crush and wave an ammonia inhalant capsule under the nose briefly if consciousness does not return within seconds of positioning.\n\nWhy: The stimulus can hasten arousal in a simple vasovagal episode.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Use an ammonia inhalant if the patient remains unconscious",
          "why": "The stimulus can hasten arousal in a simple vasovagal episode."
        },
        {
          "detail": "Track pulse, blood pressure and oxygen saturation every 1–2 minutes until the patient is fully recovered and stable.\n\nWhy: Bradycardia and hypotension are expected in vasovagal syncope but must trend toward normal, not persist.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Monitor vitals continuously",
          "why": "Bradycardia and hypotension are expected in vasovagal syncope but must trend toward normal, not persist."
        },
        {
          "detail": "Consciousness should return within 1–2 minutes and vitals should normalize.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "recovering-normally",
              "label": "Consciousness and vitals returning to normal"
            },
            {
              "goto": "s12",
              "id": "not-recovering",
              "label": "No improvement, or new signs (chest pain, irregular pulse, prolonged unconsciousness)"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient recovering as expected?"
        },
        {
          "detail": "Keep the patient reclined and monitored for at least 15 minutes after full recovery before allowing them to sit up.\n\nWhy: Sitting up too soon risks a repeat vasovagal episode.",
          "id": "s8",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 900,
          "title": "Hold the patient in recovery position for at least 15 minutes",
          "why": "Sitting up too soon risks a repeat vasovagal episode."
        },
        {
          "detail": "Before resuming or ending treatment, confirm the patient feels normal, vitals are stable, and arrange for them to be driven home rather than drive themselves if the episode was significant.\n\nWhy: A single fainting spell can recur with standing or driving stress shortly after.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Decide on same-day discharge with an escort",
          "why": "A single fainting spell can recur with standing or driving stress shortly after."
        },
        {
          "detail": "Record trigger, onset, vitals over time, interventions, recovery time, and discharge plan in the chart.\n\nRecord: Chart note: syncope episode timeline and vitals.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode resolved",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Episode resolved"
        },
        {
          "detail": "If recovery does not proceed as expected, immediately follow the universal first-response protocol (mep-001) and call 911.\n\nWhy: Atypical recovery may indicate a cardiac or other cause rather than simple syncope.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Escalate to 911 activation",
          "why": "Atypical recovery may indicate a cardiac or other cause rather than simple syncope."
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Vasovagal syncope during or after injection — A patient goes pale, sweaty and loses consciousness in the chair during or after a local anesthetic injection.",
      "title": "Vasovagal syncope during or after injection",
      "trigger": "A patient goes pale, sweaty and loses consciousness in the chair during or after a local anesthetic injection",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines and AED use",
          "source": "AHA Basic Life Support / ACLS guidelines and AED use"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3.4 Medical Emergency — Anaphylaxis (911, epinephrine 0.3mg IM anterolateral thigh, repeat 5-15min, BLS/AED if arrest) and §7.1 row",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3.4 Medical Emergency — Anaphylaxis (911, epinephrine 0.3mg IM anterolateral thigh, repeat 5-15min, BLS/AED if arrest) and §7.1 row"
        },
        {
          "kind": "open_standard",
          "label": "AAAAI/ACAAI Joint Task Force on Practice Parameters, 'Anaphylaxis — a 2023 practice parameter update': epinephrine 0.3-0.5mg IM (1mg/mL) into the anterolateral thigh as first-line treatment, may be repeated every 5-15 minutes if symptoms persist; antihistamines (e.g. diphenhydramine) are an adjunct only and never a substitute for or delay to epinephrine",
          "source": "AAAAI/ACAAI Joint Task Force on Practice Parameters, 'Anaphylaxis — a 2023 practice parameter update': epinephrine 0.3-0.5mg IM (1mg/mL) into the anterolateral thigh as first-line treatment, may be repeated every 5-15 minutes if symptoms persist; antihistamines (e.g. diphenhydramine) are an adjunct only and never a substitute for or delay to epinephrine",
          "url": "https://www.aaaai.org/Aaaai/media/Media-Library-PDFs/Allergist%20Resources/Statements%20and%20Practice%20Parameters/Anaphylaxis-Practice-Paramaters-2023.pdf"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-003",
      "kind": "clinical",
      "materials": [
        "epinephrine autoinjector 0.3mg",
        "oxygen tank + regulator + masks",
        "diphenhydramine 50mg",
        "blood pressure cuff and stethoscope",
        "pulse oximeter",
        "BVM"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Signs: hives/urticaria, lip/tongue/throat swelling, wheeze, difficulty breathing, or a sudden drop in blood pressure after exposure to a drug, latex or material. Call 911 immediately — do not wait to see if it worsens.\n\nWhy: Per DOCS/TECHNICAL_PROTOCOLS.md §7.1, anaphylaxis is a 911-first event; delay is the leading cause of preventable death in these cases.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Recognize anaphylaxis and call 911 immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Recognize anaphylaxis and call 911 immediately",
          "why": "Per DOCS/TECHNICAL_PROTOCOLS.md §7.1, anaphylaxis is a 911-first event; delay is the leading cause of preventable death in these cases."
        },
        {
          "detail": "The treating dentist (the licensed professional authorized to administer emergency medication in this state's scope of practice) confirms the diagnosis of anaphylaxis and authorizes epinephrine administration — epinephrine still goes in without delay per the emergency gate above when the treating dentist is the same person recognizing the reaction and giving the injection; this gate names who is authorizing it, it does not sequence-block the injection.\n\nWhy: Administering a prescription emergency medication is a consequential clinical act that must be owned by the licensed professional, but per AAAAI/ACAAI guidance epinephrine is the single intervention where minutes matter most — so this confirmation runs in parallel with, never ahead of, the injection when the dentist is both recognizing and giving it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist authorizes epinephrine administration.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist authorizes epinephrine administration",
          "why": "Administering a prescription emergency medication is a consequential clinical act that must be owned by the licensed professional, but per AAAAI/ACAAI guidance epinephrine is the single intervention where minutes matter most — so this confirmation runs in parallel with, never ahead of, the injection when the dentist is both recognizing and giving it."
        },
        {
          "detail": "Administer the epinephrine autoinjector (0.3mg IM) into the anterolateral thigh immediately, through clothing if necessary. Note the time given.\n\nWhy: Epinephrine is the only drug that reverses the airway swelling and hypotension of anaphylaxis; every other step is supportive.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Give epinephrine 0.3mg IM in the anterolateral thigh",
          "why": "Epinephrine is the only drug that reverses the airway swelling and hypotension of anaphylaxis; every other step is supportive."
        },
        {
          "detail": "Apply high-flow oxygen and position the patient supine with legs elevated unless they are struggling to breathe, in which case sit them upright.\n\nWhy: Positioning depends on whether hypotension or airway compromise is the dominant problem.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Give oxygen and position the patient",
          "why": "Positioning depends on whether hypotension or airway compromise is the dominant problem."
        },
        {
          "detail": "Administer diphenhydramine 50mg IM/IV as a secondary agent — never as a substitute for or delay to epinephrine.\n\nWhy: Antihistamines treat skin symptoms but do not reverse airway or cardiovascular collapse; epinephrine already given is the primary treatment.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Give diphenhydramine as an adjunct",
          "why": "Antihistamines treat skin symptoms but do not reverse airway or cardiovascular collapse; epinephrine already given is the primary treatment."
        },
        {
          "detail": "Continuously monitor airway, breathing, pulse and blood pressure. If symptoms persist or worsen after 5–15 minutes, a repeat epinephrine dose may be indicated.\n\nWhy: Per §3.4, epinephrine can be repeated in 5–15 minutes if symptoms are not resolving.",
          "id": "s6",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 600,
          "title": "Monitor for 5–15 minutes and reassess for a repeat dose",
          "why": "Per §3.4, epinephrine can be repeated in 5–15 minutes if symptoms are not resolving."
        },
        {
          "detail": "Are symptoms improving?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "improving",
              "label": "Symptoms improving, vitals stabilizing — continue monitoring until EMS arrives"
            },
            {
              "goto": "s11",
              "id": "not-improving",
              "label": "No improvement or worsening — give a second epinephrine dose"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Are symptoms improving?"
        },
        {
          "detail": "Report the exposure (drug/material/lot number if known), time of onset, epinephrine dose(s) and times given, and current vitals to EMS.\n\nWhy: EMS needs exact dosing and timing to decide on further treatment en route.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival",
          "why": "EMS needs exact dosing and timing to decide on further treatment en route."
        },
        {
          "detail": "Record the suspected trigger, timeline, doses given, vitals, and EMS disposition. Update the chart's allergy list so the trigger is never re-administered.\n\nRecord: Chart note + allergy-list update.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the reaction and flag the allergy"
        },
        {
          "detail": "Event closed — proceed to post-event debrief protocol",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Event closed — proceed to post-event debrief protocol"
        },
        {
          "detail": "Give a second 0.3mg IM dose in the opposite thigh if available, and continue BLS support until EMS arrives.\n\nWhy: A second dose is called for when the first has not reversed the reaction within the expected window.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Administer a second epinephrine dose",
          "why": "A second dose is called for when the first has not reversed the reaction within the expected window."
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Anaphylaxis — epinephrine first, EMS, airway, positioning — Within minutes of an injection, antibiotic, latex contact or material placement a patient develops hives, wheeze, lip or tongue swelling or hypotension.",
      "title": "Anaphylaxis — epinephrine first, EMS, airway, positioning",
      "trigger": "Within minutes of an injection, antibiotic, latex contact or material placement a patient develops hives, wheeze, lip or tongue swelling or hypotension",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: cardiac arrest — no pulse, unconscious — BLS/CPR; AED; 911",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: cardiac arrest — no pulse, unconscious — BLS/CPR; AED; 911"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-004",
      "kind": "clinical",
      "materials": [
        "AED",
        "BVM",
        "oxygen tank + regulator + masks",
        "CPR barrier mask"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Check responsiveness and breathing for no more than 10 seconds. If unresponsive and not breathing normally (or only gasping), call 911 immediately and begin chest compressions without delay. If a DNR/POLST chart flag (mep-022) is immediately visible, glance at it in parallel — never pause or search for one before starting compressions.\n\nWhy: Every minute without compressions after cardiac arrest reduces survival odds; BLS guidelines call for compressions to start within seconds of recognition. A known, already-flagged DNR/POLST scope (mep-022) is read in parallel with, never in place of, starting compressions on recognition.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm unresponsive and not breathing normally — call 911 and begin CPR.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm unresponsive and not breathing normally — call 911 and begin CPR",
          "why": "Every minute without compressions after cardiac arrest reduces survival odds; BLS guidelines call for compressions to start within seconds of recognition. A known, already-flagged DNR/POLST scope (mep-022) is read in parallel with, never in place of, starting compressions on recognition."
        },
        {
          "detail": "The dentist, or the most BLS/CPR-certified staff member present if the dentist is not immediately available, confirms cardiac arrest and takes charge of the resuscitation — compressions still start without delay per the emergency gate above; this confirms who is directing it.\n\nWhy: Someone certified must own the resuscitation's direction (compression rotation, AED prompts, EMS handoff) even though the compressions themselves cannot wait on this confirmation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist (or most-qualified certified responder) confirms and leads resuscitation.",
            "role": "dentist or senior BLS-certified staff",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist (or most-qualified certified responder) confirms and leads resuscitation",
          "why": "Someone certified must own the resuscitation's direction (compression rotation, AED prompts, EMS handoff) even though the compressions themselves cannot wait on this confirmation."
        },
        {
          "detail": "Start high-quality chest compressions at the current BLS-recommended rate and depth on a firm surface, minimizing interruptions.\n\nWhy: Continuous compressions maintain blood flow to the brain and heart until a shockable rhythm can be treated.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Begin chest compressions immediately",
          "why": "Continuous compressions maintain blood flow to the brain and heart until a shockable rhythm can be treated."
        },
        {
          "detail": "A second staff member retrieves the AED and confirms 911 has been called, while compressions continue uninterrupted.\n\nWhy: Compressions must not stop to retrieve equipment — a dedicated second responder keeps both tasks moving in parallel.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Send a second person for the AED and to call 911 if not already done",
          "why": "Compressions must not stop to retrieve equipment — a dedicated second responder keeps both tasks moving in parallel."
        },
        {
          "detail": "As soon as the AED arrives, turn it on, attach pads per the diagram, and follow its prompts exactly, pausing compressions only when the device instructs.\n\nWhy: AEDs are designed to guide a lay responder through rhythm analysis and shock delivery safely.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Attach the AED and follow its voice prompts",
          "why": "AEDs are designed to guide a lay responder through rhythm analysis and shock delivery safely."
        },
        {
          "detail": "Does the AED advise a shock?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "shock-advised",
              "label": "Shock advised — clear the patient and deliver it, then resume CPR immediately"
            },
            {
              "goto": "s7",
              "id": "no-shock-advised",
              "label": "No shock advised — resume CPR immediately"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the AED advise a shock?"
        },
        {
          "detail": "Continue compression/AED cycles, rotating the compressing team member roughly every 2 minutes to avoid fatigue-degraded compressions, until EMS takes over.\n\nWhy: Compression quality degrades with rescuer fatigue; scheduled rotation keeps it consistent.",
          "id": "s7",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 120,
          "title": "Continue CPR cycles until EMS arrives or the AED re-prompts",
          "why": "Compression quality degrades with rescuer fatigue; scheduled rotation keeps it consistent."
        },
        {
          "detail": "Continue CPR until EMS personnel are physically ready to take over, then report time of collapse, time CPR started, number of shocks delivered, and any medical history known.\n\nWhy: A clean handoff with exact timing lets EMS pick up without a gap in care.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival",
          "why": "A clean handoff with exact timing lets EMS pick up without a gap in care."
        },
        {
          "detail": "Record time of collapse, time CPR started, AED shocks delivered and times, EMS arrival time, and outcome/disposition.\n\nRecord: Chart or incident note: full resuscitation timeline.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the resuscitation"
        },
        {
          "detail": "Event closed — proceed to post-event debrief protocol",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Event closed — proceed to post-event debrief protocol"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Cardiac arrest — CPR, AED, EMS — A patient, visitor or staff member collapses, is unresponsive and not breathing normally.",
      "title": "Cardiac arrest — CPR, AED, EMS",
      "trigger": "A patient, visitor or staff member collapses, is unresponsive and not breathing normally",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines",
          "source": "AHA Basic Life Support / ACLS guidelines"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 rows: angina (nitro sublingual, O2, 911 if no relief) and MI suspected (911 immediately, aspirin 325mg PO if not allergic)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 rows: angina (nitro sublingual, O2, 911 if no relief) and MI suspected (911 immediately, aspirin 325mg PO if not allergic)"
        },
        {
          "kind": "regulation",
          "label": "FDA-approved prescribing information for sildenafil citrate (PDE5 inhibitor class labeling): co-administration with organic nitrates in any form is contraindicated because it potentiates the hypotensive effect of nitrates, and how long after a PDE5 inhibitor dose it becomes safe to give nitrates is not established — the practice's own written protocol should set a conservative screening window (commonly cited as roughly 24-72 hours depending on the specific PDE5 inhibitor)",
          "source": "FDA-approved prescribing information for sildenafil citrate (PDE5 inhibitor class labeling): co-administration with organic nitrates in any form is contraindicated because it potentiates the hypotensive effect of nitrates, and how long after a PDE5 inhibitor dose it becomes safe to give nitrates is not established — the practice's own written protocol should set a conservative screening window (commonly cited as roughly 24-72 hours depending on the specific PDE5 inhibitor)",
          "url": "https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/20895s039s042lbl.pdf"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-005",
      "kind": "clinical",
      "materials": [
        "nitroglycerin sublingual 0.4mg",
        "aspirin 325mg",
        "oxygen tank + regulator + masks",
        "blood pressure cuff and stethoscope",
        "pulse oximeter"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Stop the dental procedure. Ask about pain quality, radiation, and duration. If severe, crushing, radiating to arm/jaw, or accompanied by shortness of breath/sweating, call 911 without waiting for nitroglycerin to work.\n\nWhy: Distinguishing angina from suspected MI changes management, but both start with stopping treatment and assessing urgently; a 911 call should not be delayed pending a trial of nitroglycerin.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop treatment and assess chest pain immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Stop treatment and assess chest pain immediately",
          "why": "Distinguishing angina from suspected MI changes management, but both start with stopping treatment and assessing urgently; a 911 call should not be delayed pending a trial of nitroglycerin."
        },
        {
          "detail": "The treating dentist confirms the clinical picture and authorizes any nitroglycerin or aspirin administration before it is given, per the decision steps below.\n\nWhy: Administering a cardiac medication, even an over-the-counter one like aspirin, in an emergency context is a consequential clinical act requiring the licensed professional's authorization.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist authorizes nitroglycerin/aspirin administration.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist authorizes nitroglycerin/aspirin administration",
          "why": "Administering a cardiac medication, even an over-the-counter one like aspirin, in an emergency context is a consequential clinical act requiring the licensed professional's authorization."
        },
        {
          "detail": "Sit the patient in a comfortable, usually semi-upright position, apply oxygen, and take blood pressure, pulse and oxygen saturation. Ask: has the patient taken sildenafil, tadalafil or vardenafil (or a similar erectile-dysfunction or pulmonary-hypertension medication) in roughly the past 24-72 hours? Note the answer for the nitroglycerin decision below.\n\nWhy: Baseline vitals guide whether nitroglycerin is safe (it lowers blood pressure), and PDE5-inhibitor co-administration with a nitrate is contraindicated (can cause severe, refractory hypotension) — both must be known before nitroglycerin is offered.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Position upright, apply oxygen, take vitals, screen for PDE5-inhibitor use",
          "why": "Baseline vitals guide whether nitroglycerin is safe (it lowers blood pressure), and PDE5-inhibitor co-administration with a nitrate is contraindicated (can cause severe, refractory hypotension) — both must be known before nitroglycerin is offered."
        },
        {
          "detail": "Is nitroglycerin available and safe to give — no PDE5-inhibitor use, and systolic BP at or above roughly 90-100mmHg?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "give-nitro",
              "label": "Known cardiac history, has/can safely receive nitroglycerin, no sildenafil/tadalafil/vardenafil in the past 24-72 hours, systolic BP at or above roughly 90-100mmHg (or per the practice's own written protocol) — give nitroglycerin sublingual 0.4mg"
            },
            {
              "goto": "s9",
              "id": "no-nitro",
              "label": "No nitroglycerin available, systolic BP below roughly 90-100mmHg, or the patient has taken sildenafil/tadalafil/vardenafil within 24-72 hours — do not give nitroglycerin; call 911 immediately and skip to aspirin decision"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is nitroglycerin available and safe to give — no PDE5-inhibitor use, and systolic BP at or above roughly 90-100mmHg?"
        },
        {
          "detail": "Administer one sublingual nitroglycerin 0.4mg dose. If pain persists after several minutes, this is treated as a possible MI — call 911 immediately.\n\nWhy: Per §7.1, angina pain relieved by nitroglycerin is managed conservatively; pain not relieved escalates to suspected MI and 911.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Give nitroglycerin sublingual 0.4mg",
          "why": "Per §7.1, angina pain relieved by nitroglycerin is managed conservatively; pain not relieved escalates to suspected MI and 911."
        },
        {
          "detail": "Did the pain resolve with nitroglycerin?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "relieved",
              "label": "Pain resolved — monitor, arrange transport home, advise follow-up with physician"
            },
            {
              "goto": "s9",
              "id": "not-relieved",
              "label": "Pain persists or worsens — call 911 immediately (suspected MI)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Did the pain resolve with nitroglycerin?"
        },
        {
          "detail": "Record onset, description, interventions and times, vitals, and disposition (resolved / transported).\n\nRecord: Chart note: chest pain event timeline.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the event"
        },
        {
          "detail": "Event closed — proceed to post-event debrief protocol",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Event closed — proceed to post-event debrief protocol"
        },
        {
          "detail": "Call 911 immediately and state suspected cardiac event.\n\nWhy: Time to definitive cardiac care is the primary driver of outcome in MI.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Call 911 for suspected myocardial infarction",
          "why": "Time to definitive cardiac care is the primary driver of outcome in MI."
        },
        {
          "detail": "Confirm the patient is not allergic to aspirin and has no active bleeding contraindication, then have them chew and swallow 325mg aspirin.\n\nWhy: Per §7.1, aspirin is given for suspected MI unless allergic — it reduces clot progression while awaiting EMS.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Give aspirin 325mg by mouth if not allergic",
          "why": "Per §7.1, aspirin is given for suspected MI unless allergic — it reduces clot progression while awaiting EMS."
        },
        {
          "detail": "Report pain onset time, description, interventions given (nitroglycerin, aspirin) and times, vitals trend, and cardiac history.\n\nWhy: EMS treatment decisions depend on exactly what was already given and when.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival",
          "why": "EMS treatment decisions depend on exactly what was already given and when."
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Chest pain — angina versus suspected myocardial infarction — A patient reports crushing or radiating chest pain, or a known cardiac patient becomes diaphoretic and short of breath mid-appointment.",
      "title": "Chest pain — angina versus suspected myocardial infarction",
      "trigger": "A patient reports crushing or radiating chest pain, or a known cardiac patient becomes diaphoretic and short of breath mid-appointment",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "American Stroke Association FAST recognition method (public education material)",
          "source": "American Stroke Association FAST recognition method (public education material)"
        },
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support guidelines",
          "source": "AHA Basic Life Support guidelines"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 severity triage rule (911 first)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 severity triage rule (911 first)"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "mep-006",
      "kind": "clinical",
      "materials": [
        "blood pressure cuff and stethoscope",
        "pulse oximeter",
        "glucometer",
        "clock or timer"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Check Face (ask the patient to smile — look for facial droop), Arms (ask them to raise both arms — look for one drifting down), Speech (ask them to repeat a simple phrase — listen for slurring). If any sign is present, call 911 immediately — Time is the fourth letter: note the exact time symptoms began or were last seen normal.\n\nWhy: FAST is the public-domain stroke recognition method; time-to-treatment for stroke is the single largest driver of outcome, so 911 is called on recognition, not after a full workup.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Run the FAST check and call 911 immediately if any sign is present.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Run the FAST check and call 911 immediately if any sign is present",
          "why": "FAST is the public-domain stroke recognition method; time-to-treatment for stroke is the single largest driver of outcome, so 911 is called on recognition, not after a full workup."
        },
        {
          "detail": "The dentist confirms the FAST check result and takes over directing the response — the 911 call itself is never delayed for this confirmation.\n\nWhy: A licensed professional's confirmation anchors what gets reported to EMS and later documented; it happens in parallel with, not instead of, the 911 call already placed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the FAST findings before the office relies on them.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the FAST findings before the office relies on them",
          "why": "A licensed professional's confirmation anchors what gets reported to EMS and later documented; it happens in parallel with, not instead of, the 911 call already placed."
        },
        {
          "detail": "Ask the patient or note directly the precise time symptoms started, or the last time the patient was seen acting normally if onset is unwitnessed.\n\nWhy: This 'last known well' time determines whether the patient is a candidate for time-sensitive stroke treatments at the hospital.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Record the exact time symptoms began or were last known normal",
          "why": "This 'last known well' time determines whether the patient is a candidate for time-sensitive stroke treatments at the hospital."
        },
        {
          "detail": "Keep the patient calm and seated or reclined, monitor blood pressure, pulse and oxygen saturation, and give nothing by mouth.\n\nWhy: Swallowing may be impaired in stroke; giving food or drink risks aspiration.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Keep the patient still, monitor vitals, do not give food or drink",
          "why": "Swallowing may be impaired in stroke; giving food or drink risks aspiration."
        },
        {
          "detail": "Take a quick fingerstick glucose reading if equipment and training allow.\n\nWhy: Severe hypoglycemia can mimic stroke signs; ruling it out (or treating it) can be relevant information for EMS without delaying the 911 call already made.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Check blood glucose if a glucometer is available",
          "why": "Severe hypoglycemia can mimic stroke signs; ruling it out (or treating it) can be relevant information for EMS without delaying the 911 call already made."
        },
        {
          "detail": "Report the FAST findings, exact onset/last-known-well time, vitals, glucose reading, and any medication history (especially blood thinners).\n\nWhy: Onset time and anticoagulant use directly affect what treatment the hospital can offer.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival",
          "why": "Onset time and anticoagulant use directly affect what treatment the hospital can offer."
        },
        {
          "detail": "Record FAST findings, onset/last-known-well time, vitals, and EMS disposition.\n\nRecord: Chart note: stroke recognition timeline.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the event"
        },
        {
          "detail": "Event closed — proceed to post-event debrief protocol",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Event closed — proceed to post-event debrief protocol"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Suspected stroke — face, arm, speech, time recognition and response — A patient develops facial droop, arm weakness, slurred speech or sudden confusion at any point in the visit.",
      "title": "Suspected stroke — face, arm, speech, time recognition and response",
      "trigger": "A patient develops facial droop, arm weakness, slurred speech or sudden confusion at any point in the visit",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support guidelines",
          "source": "AHA Basic Life Support guidelines"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "url": "https://www.ada.org/resources/ada-library/oral-health-topics/medical-emergencies-in-the-dental-office"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: seizure — convulsion — protect from injury, do NOT restrain, O2 after, 911 if >5 min",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: seizure — convulsion — protect from injury, do NOT restrain, O2 after, 911 if >5 min"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "mep-007",
      "kind": "clinical",
      "materials": [
        "oxygen tank + regulator + masks",
        "pulse oximeter",
        "clock or timer",
        "soft padding/blanket"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "The moment convulsions begin, note the start time. If this is a known seizure disorder and the seizure resolves within a few minutes with normal recovery, EMS is not automatically required — but if it is the patient's first seizure, lasts more than 5 minutes, or a second seizure follows without full recovery, call 911 immediately.\n\nWhy: Per §7.1, seizures longer than 5 minutes require 911; a first-ever seizure or a cluster is treated as an emergency regardless of duration because the underlying cause is unknown.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Recognize seizure onset, clear the area, and start timing.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Recognize seizure onset, clear the area, and start timing",
          "why": "Per §7.1, seizures longer than 5 minutes require 911; a first-ever seizure or a cluster is treated as an emergency regardless of duration because the underlying cause is unknown."
        },
        {
          "detail": "The dentist confirms, based on known seizure history and duration, whether this event follows the known-disorder monitoring pathway or needs immediate 911 — instrument clearance and injury protection below happen regardless and are never delayed for this confirmation.\n\nWhy: The decision of which pathway applies is a clinical judgment call that belongs to the licensed professional, even though the immediate safety steps do not wait on it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the response plan (911 now vs. monitor to resolution).",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the response plan (911 now vs. monitor to resolution)",
          "why": "The decision of which pathway applies is a clinical judgment call that belongs to the licensed professional, even though the immediate safety steps do not wait on it."
        },
        {
          "detail": "Pull all dental instruments, suction tips and materials away from the patient's face and mouth the instant convulsions start. Do not attempt to place anything in the mouth.\n\nWhy: Instruments in or near the mouth during a seizure are a laceration and aspiration hazard; nothing should ever be forced into a seizing patient's mouth.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Immediately remove all instruments and sharps from the patient's mouth and reach",
          "why": "Instruments in or near the mouth during a seizure are a laceration and aspiration hazard; nothing should ever be forced into a seizing patient's mouth."
        },
        {
          "detail": "Move the chair and nearby equipment away, protect the head with soft padding, and clear the immediate area. Do not physically restrain the patient's limbs.\n\nWhy: Restraining a seizing person does not stop the seizure and can cause fractures or dislocations; the goal is only to prevent injury from the environment.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Protect from injury — do not restrain",
          "why": "Restraining a seizing person does not stop the seizure and can cause fractures or dislocations; the goal is only to prevent injury from the environment."
        },
        {
          "detail": "As soon as active convulsions end, turn the patient onto their side (recovery position) to protect the airway from secretions or vomit.\n\nWhy: Post-seizure patients often have reduced airway reflexes; side-lying allows drainage away from the airway.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Turn the patient onto their side once convulsions stop",
          "why": "Post-seizure patients often have reduced airway reflexes; side-lying allows drainage away from the airway."
        },
        {
          "detail": "Apply oxygen once active convulsions have stopped, and monitor breathing and oxygen saturation during the postictal recovery period.\n\nWhy: Oxygen is given after, not during, active convulsions per §7.1 to avoid interfering with airway protection during the seizure itself.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Give oxygen after the seizure ends",
          "why": "Oxygen is given after, not during, active convulsions per §7.1 to avoid interfering with airway protection during the seizure itself."
        },
        {
          "detail": "Did the seizure last more than 5 minutes, recur, or is this a first-time seizure?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "resolved-known",
              "label": "Known seizure disorder, resolved under 5 minutes, normal recovery — monitor and arrange escorted discharge"
            },
            {
              "goto": "s10",
              "id": "needs-911",
              "label": "First seizure, over 5 minutes, or recurs without full recovery — call 911"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Did the seizure last more than 5 minutes, recur, or is this a first-time seizure?"
        },
        {
          "detail": "Record start and end time, description of movements, postictal state, interventions, and disposition.\n\nRecord: Chart note: seizure event timeline.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the seizure"
        },
        {
          "detail": "Event closed — proceed to post-event debrief protocol",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Event closed — proceed to post-event debrief protocol"
        },
        {
          "detail": "Call 911 and continue monitoring airway, breathing and circulation while awaiting EMS.\n\nWhy: These presentations may indicate status epilepticus or an unknown underlying cause requiring emergency evaluation.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Call 911",
          "why": "These presentations may indicate status epilepticus or an unknown underlying cause requiring emergency evaluation."
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Seizure in the operatory or reception area — A patient begins convulsing in the chair or in the reception area.",
      "title": "Seizure in the operatory or reception area",
      "trigger": "A patient begins convulsing in the chair or in the reception area",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "url": "https://www.ada.org/resources/ada-library/oral-health-topics/medical-emergencies-in-the-dental-office"
        },
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support guidelines",
          "source": "AHA Basic Life Support guidelines"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: hypoglycemia — confusion, diaphoresis — if conscious: 15g fast-acting carbs, glucose gel, 911 if unconscious",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 row: hypoglycemia — confusion, diaphoresis — if conscious: 15g fast-acting carbs, glucose gel, 911 if unconscious"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "mep-008",
      "kind": "clinical",
      "materials": [
        "glucose oral gel/tablets",
        "glucometer",
        "oxygen tank + regulator + masks",
        "pulse oximeter"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the patient is unresponsive or cannot safely swallow, treat this as an emergency and call 911 immediately — do not attempt to give anything by mouth to an unconscious patient. If conscious and able to swallow, proceed to the conscious pathway.\n\nWhy: Giving oral glucose to an unconscious patient is an aspiration risk; consciousness and swallow ability determine the entire treatment path.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Recognize possible hypoglycemia and check responsiveness first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Recognize possible hypoglycemia and check responsiveness first",
          "why": "Giving oral glucose to an unconscious patient is an aspiration risk; consciousness and swallow ability determine the entire treatment path."
        },
        {
          "detail": "The treating dentist confirms consciousness/swallow-safety status and authorizes the corresponding treatment pathway (oral glucose vs. 911).\n\nWhy: Choosing between an oral intervention and an emergency call is a consequential clinical decision that the licensed professional must own.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist authorizes the glucose treatment pathway.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist authorizes the glucose treatment pathway",
          "why": "Choosing between an oral intervention and an emergency call is a consequential clinical decision that the licensed professional must own."
        },
        {
          "detail": "Is the patient conscious and able to swallow safely?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "conscious-path",
              "label": "Conscious and able to swallow — give fast-acting carbohydrate"
            },
            {
              "goto": "s9",
              "id": "unconscious-path",
              "label": "Unconscious or unable to swallow safely — call 911"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient conscious and able to swallow safely?"
        },
        {
          "detail": "Give approximately 15 grams of fast-acting carbohydrate (glucose gel or tablets, or juice/regular soda if that is what is on hand) by mouth.\n\nWhy: Per §7.1, 15g fast-acting carbs is the standard conscious-patient treatment for suspected hypoglycemia.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Give 15g of fast-acting carbohydrate",
          "why": "Per §7.1, 15g fast-acting carbs is the standard conscious-patient treatment for suspected hypoglycemia."
        },
        {
          "detail": "Wait about 15 minutes, then reassess the patient's symptoms and recheck blood glucose with a glucometer if available.\n\nWhy: Symptom relief and a glucose recheck confirm the intervention worked rather than assuming it did.",
          "id": "s5",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 900,
          "title": "Wait 15 minutes and recheck symptoms/glucose",
          "why": "Symptom relief and a glucose recheck confirm the intervention worked rather than assuming it did."
        },
        {
          "detail": "Have symptoms improved?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "improved",
              "label": "Symptoms improved — give a small snack, monitor, then may resume or reschedule treatment"
            },
            {
              "goto": "s10",
              "id": "not-improved",
              "label": "No improvement — give a second 15g dose, and call 911 if still not improving after that"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Have symptoms improved?"
        },
        {
          "detail": "Record onset, glucose readings, interventions and times, and outcome/disposition.\n\nRecord: Chart note: hypoglycemia event timeline.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the event"
        },
        {
          "detail": "Event closed — proceed to post-event debrief protocol",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Event closed — proceed to post-event debrief protocol"
        },
        {
          "detail": "Call 911, provide oxygen if not already given, and monitor airway, breathing and circulation while awaiting EMS.\n\nWhy: Unconsciousness or non-response to treatment is an emergency requiring professional evaluation and, potentially, IV or injectable glucose/glucagon.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Call 911",
          "why": "Unconsciousness or non-response to treatment is an emergency requiring professional evaluation and, potentially, IV or injectable glucose/glucagon."
        },
        {
          "detail": "Give a second 15g fast-acting carbohydrate dose. If there is still no improvement, or the patient's condition worsens or level of consciousness drops, call 911 immediately.\n\nWhy: Repeated non-response raises the possibility of a cause beyond simple hypoglycemia requiring evaluation.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Give a second dose and escalate if needed",
          "why": "Repeated non-response raises the possibility of a cause beyond simple hypoglycemia requiring evaluation."
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Hypoglycemia — conscious and unconscious pathways — A diabetic patient becomes confused, shaky, sweaty or drowsy, typically after skipping a meal before a long appointment.",
      "title": "Hypoglycemia — conscious and unconscious pathways",
      "trigger": "A diabetic patient becomes confused, shaky, sweaty or drowsy, typically after skipping a meal before a long appointment",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "open_standard",
          "label": "ADA office medical emergencies guidance — respiratory distress: O2, assess cause, bronchodilator if asthma, 911",
          "source": "ADA office medical emergencies guidance — respiratory distress: O2, assess cause, bronchodilator if asthma, 911"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-009",
      "kind": "clinical",
      "materials": [
        "oxygen tank, regulator and adult/child masks",
        "pulse oximeter",
        "bronchodilator inhaler with spacer",
        "blood pressure cuff and stethoscope",
        "emergency drug kit"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Stop the procedure immediately. Direct a team member to call 911 now, state the office address and 'possible asthma emergency, patient in respiratory distress,' and stay on the line. Do not wait for EMS to start first aid.\n\nWhy: Simultaneous EMS activation and first aid gives the best outcome; per DOCS/TECHNICAL_PROTOCOLS.md §7.1 respiratory distress with wheeze/dyspnea calls for O2, cause assessment, bronchodilator and 911 together, not in sequence.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Activate 911 while first aid begins.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Activate 911 while first aid begins",
          "why": "Simultaneous EMS activation and first aid gives the best outcome; per DOCS/TECHNICAL_PROTOCOLS.md §7.1 respiratory distress with wheeze/dyspnea calls for O2, cause assessment, bronchodilator and 911 together, not in sequence."
        },
        {
          "detail": "Raise the chair to a fully upright seated position, loosen the bib and any restrictive clothing, and remove any airborne irritant (aerosol, powder, latex item) from the room.\n\nWhy: An upright position and removal of the triggering irritant reduce airway resistance while oxygen and treatment are readied.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Sit the patient fully upright",
          "why": "An upright position and removal of the triggering irritant reduce airway resistance while oxygen and treatment are readied."
        },
        {
          "detail": "Retrieve the oxygen tank with adult/child mask, pulse oximeter, blood pressure cuff, and the bronchodilator inhaler with spacer from the emergency drug kit.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Bring the emergency kit and monitors"
        },
        {
          "detail": "Apply oxygen by mask or nasal cannula at a low flow rate and place the pulse oximeter on a finger; record the first saturation and pulse reading out loud for the recorder.\n\nWhy: Continuous saturation monitoring tells the team whether the response is working before EMS arrives.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Apply oxygen and start monitoring",
          "why": "Continuous saturation monitoring tells the team whether the response is working before EMS arrives."
        },
        {
          "detail": "Check whether the patient carries their own prescribed rescue inhaler, whether the office kit inhaler may be used for this patient under the medical director's standing order, or neither applies.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "own-inhaler",
              "label": "Patient has a prescribed rescue inhaler — assist self-administration"
            },
            {
              "goto": "s12",
              "id": "kit-inhaler",
              "label": "No prescribed inhaler of the patient's own, but the office kit inhaler is stocked and the medical director's standing order covers this patient — use the office kit inhaler"
            },
            {
              "goto": "s8",
              "id": "no-inhaler",
              "label": "Neither the patient's own inhaler nor the office kit inhaler applies — continue oxygen only and wait for EMS"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a rescue bronchodilator available for this patient?"
        },
        {
          "detail": "Dentist confirms the patient's known allergy history and authorizes the assistant to help the patient self-administer their own rescue inhaler through the spacer, per the patient's prescribed dose.\n\nWhy: Assisting with a patient's own prescribed medication under direct licensed supervision is the consequential clinical step that needs a named sign-off before it happens.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist authorizes assisted inhaler use.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist authorizes assisted inhaler use",
          "why": "Assisting with a patient's own prescribed medication under direct licensed supervision is the consequential clinical step that needs a named sign-off before it happens."
        },
        {
          "detail": "Help the patient hold and trigger their inhaler through the spacer, coaching a slow deep breath and 10-second hold, while oxygen and monitoring continue.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Assist self-administration of the rescue inhaler"
        },
        {
          "detail": "Continue oxygen and pulse-oximeter monitoring for 5 minutes, watching breathing rate, use of accessory muscles, and saturation trend.",
          "id": "s8",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 300,
          "title": "Observe response for 5 minutes"
        },
        {
          "detail": "Compare current breathing effort and saturation to the baseline reading taken at the start of monitoring.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "improved",
              "label": "Breathing and saturation improved — continue supportive care, hold elective treatment"
            },
            {
              "goto": "s14",
              "id": "not-improved",
              "label": "No improvement or worsening — treat as severe, prepare for EMS handoff"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Has breathing improved?"
        },
        {
          "detail": "Record onset time, symptoms, actions taken, vitals trend, medications administered, response, and EMS involvement in the patient chart per DOCS/TECHNICAL_PROTOCOLS.md §8.1 SOAP format.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode closed",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Episode closed"
        },
        {
          "detail": "Dentist confirms the patient's known allergy history, confirms the medical director's standing order covers administering the office kit's bronchodilator inhaler to a non-prescribed patient in this emergency, and authorizes the assistant to help the patient use it through the spacer.\n\nWhy: Giving a patient a medication that is not their own prescription — even from the office emergency kit, in an emergency — is a consequential clinical act that needs a named licensed sign-off tied explicitly to the standing order authorizing it, separate from the sign-off used for a patient's own inhaler.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist authorizes office-kit inhaler use under the medical director's standing order.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist authorizes office-kit inhaler use under the medical director's standing order",
          "why": "Giving a patient a medication that is not their own prescription — even from the office emergency kit, in an emergency — is a consequential clinical act that needs a named licensed sign-off tied explicitly to the standing order authorizing it, separate from the sign-off used for a patient's own inhaler."
        },
        {
          "detail": "Help the patient hold and trigger the office kit's bronchodilator inhaler through the spacer, coaching a slow deep breath and 10-second hold, while oxygen and monitoring continue.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Assist use of the office kit rescue inhaler"
        },
        {
          "detail": "Give EMS a verbal summary: onset time, symptoms observed, oxygen and inhaler given, saturation trend, and any known asthma or allergy history from the chart.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Asthma attack or bronchospasm response — oxygen, bronchodilator, 911 escalation — A patient begins wheezing and struggling to breathe in the chair, with or without a known asthma history.",
      "title": "Asthma attack or bronchospasm response — oxygen, bronchodilator, 911 escalation",
      "trigger": "A patient begins wheezing and struggling to breathe in the chair, with or without a known asthma history",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "open_standard",
          "label": "ADA office medical emergencies guidance — rule out organic causes (hypoglycemia, asthma, cardiac) before treating as anxiety-driven hyperventilation",
          "source": "ADA office medical emergencies guidance — rule out organic causes (hypoglycemia, asthma, cardiac) before treating as anxiety-driven hyperventilation"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 12,
      "frequency": "as-needed",
      "id": "mep-010",
      "kind": "clinical",
      "materials": [
        "pulse oximeter",
        "blood pressure cuff and stethoscope",
        "glucometer",
        "oxygen tank and mask"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Stay at the patient's side and calmly assess breathing and consciousness. If breathing does not slow within a few minutes, symptoms worsen, or the patient loses consciousness, direct a team member to call 911 immediately.\n\nWhy: Most hyperventilation is anxiety-driven and resolves with coaching, but the entry step names the 911 escalation up front so no one hesitates if the picture changes — per non-negotiable emergency-guard shape.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stay with the patient; keep 911 ready.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Stay with the patient; keep 911 ready",
          "why": "Most hyperventilation is anxiety-driven and resolves with coaching, but the entry step names the 911 escalation up front so no one hesitates if the picture changes — per non-negotiable emergency-guard shape."
        },
        {
          "detail": "Stop the procedure, raise the chair upright, and remove any mask, rubber dam or instrument from the mouth so the patient can speak freely.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Stop treatment and reposition upright"
        },
        {
          "detail": "Check pulse oximeter reading, blood pressure, and (if diabetic) blood glucose; ask about chest pain, known asthma, or recent medication/anesthetic given — any of these redirect to the matching protocol instead of coaching.\n\nWhy: Rapid breathing can be the first sign of hypoglycemia, asthma or a cardiac event, not just anxiety; ruling those out first is standard office guidance before treating hyperventilation as benign.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Screen for an organic cause before treating as anxiety",
          "why": "Rapid breathing can be the first sign of hypoglycemia, asthma or a cardiac event, not just anxiety; ruling those out first is standard office guidance before treating hyperventilation as benign."
        },
        {
          "detail": "Weigh the vitals and history just gathered.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-organic-cause",
              "label": "Vitals and history are unremarkable — proceed with calming coaching"
            },
            {
              "goto": "s11",
              "id": "organic-cause-found",
              "label": "A likely organic cause is found — switch to the matching emergency protocol (hypoglycemia, asthma, chest pain)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Does an organic cause explain the symptoms?"
        },
        {
          "detail": "In a calm, low voice, coach the patient through slow breaths — in for 4 counts, hold for 4, out for 6 — and reassure them that the symptoms will pass; sit at eye level rather than standing over the chair.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Coach slow, paced breathing"
        },
        {
          "detail": "Continue coaching and monitor pulse oximeter and breathing rate for 5 minutes while the patient calms.",
          "id": "s6",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 300,
          "title": "Observe for 5 minutes"
        },
        {
          "detail": "Compare current breathing rate and demeanor to onset.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "calmed",
              "label": "Breathing has slowed and symptoms have resolved — proceed to sign-off on resuming or rescheduling"
            },
            {
              "goto": "s11",
              "id": "not-calmed",
              "label": "No improvement after coaching — treat as escalating, call or confirm 911"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Has the patient calmed?"
        },
        {
          "detail": "Dentist confirms the patient is calm, vitals are normal, and no organic cause was found, then makes the explicit call: resume the appointment today or reschedule by patient preference.\n\nWhy: Deciding to resume dental treatment right after an anxiety episode is a clinical judgment call — resuming too soon can retrigger the episode — so it gets a named sign-off rather than defaulting silently to 'resume.'",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist decides whether to resume treatment today.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist decides whether to resume treatment today",
          "why": "Deciding to resume dental treatment right after an anxiety episode is a clinical judgment call — resuming too soon can retrigger the episode — so it gets a named sign-off rather than defaulting silently to 'resume.'"
        },
        {
          "detail": "Record onset, vitals, screening findings, coaching given, and outcome in the chart per DOCS/TECHNICAL_PROTOCOLS.md §8.1.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode closed",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Episode closed"
        },
        {
          "detail": "Hand the patient's status and vitals to whichever response applies — the hypoglycemia, asthma or chest-pain protocol, or EMS on arrival — with a verbal summary of onset, vitals and actions taken.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the matching protocol or EMS"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Hyperventilation or panic attack — calming coaching with a safety net for organic causes — An anxious patient breathes rapidly with tingling fingers and lightheadedness.",
      "title": "Hyperventilation or panic attack — calming coaching with a safety net for organic causes",
      "trigger": "An anxious patient breathes rapidly with tingling fingers and lightheadedness",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "open_standard",
          "label": "AHA/Red Cross adult choking response algorithm — encourage forceful cough; if airway obstructed, abdominal thrusts; CPR if unresponsive",
          "source": "AHA/Red Cross adult choking response algorithm — encourage forceful cough; if airway obstructed, abdominal thrusts; CPR if unresponsive"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-011",
      "kind": "clinical",
      "materials": [
        "oxygen tank, regulator and masks",
        "pulse oximeter",
        "suction",
        "rubber dam and floss-tie kit (prevention)",
        "AED"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If the patient cannot cough, speak, or make sound, direct a team member to call 911 immediately and begin the choking response without delay.\n\nWhy: A complete airway obstruction is immediately life-threatening; the entry gate names 911 first even though first-aid maneuvers begin in the same moment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: If the patient cannot cough, speak or breathe, call 911 now.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "assistant",
          "title": "If the patient cannot cough, speak or breathe, call 911 now",
          "why": "A complete airway obstruction is immediately life-threatening; the entry gate names 911 first even though first-aid maneuvers begin in the same moment."
        },
        {
          "detail": "Ask the patient to cough or speak; watch chest and airway effort.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "forceful-cough",
              "label": "Forceful cough or speech present — encourage coughing, do not intervene manually"
            },
            {
              "goto": "s9",
              "id": "no-cough-or-breath",
              "label": "Weak or no cough, cannot breathe — begin abdominal thrusts"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Can the patient cough forcefully or speak?"
        },
        {
          "detail": "Encourage the patient to keep coughing, position them leaning slightly forward, and suction the mouth to clear visible debris without reaching blindly toward the throat.\n\nWhy: A patient who can still cough forcefully is moving air; blind finger sweeps can push an object deeper.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Encourage forceful coughing and suction the mouth",
          "why": "A patient who can still cough forcefully is moving air; blind finger sweeps can push an object deeper."
        },
        {
          "detail": "Determine whether the object was expelled/aspirated (needs imaging) versus swallowed and the patient is breathing normally throughout.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "swallowed-stable",
              "label": "Object swallowed, patient breathing normally, no distress — arrange physician/imaging referral, no EMS required"
            },
            {
              "goto": "s11",
              "id": "possible-aspiration",
              "label": "Possible aspiration into the airway or ongoing symptoms — call 911 for evaluation even though breathing improved"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this a cleared aspiration risk, or a swallowed object with normal breathing?"
        },
        {
          "detail": "Call the patient's physician or a same-day urgent care/ENT to arrange imaging (X-ray) to confirm the object's path and rule out aspiration; give the object's size, shape and material.",
          "id": "s5",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Arrange physician or ENT referral for a swallowed object"
        },
        {
          "detail": "Dentist confirms in writing which pathway was taken (referral vs EMS) and that the patient or caregiver understands the follow-up plan before the patient leaves the office.\n\nWhy: A swallowed/aspirated foreign body has real airway and GI risk even after apparent recovery; a named sign-off keeps the office from letting the patient leave without a confirmed follow-up path.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the referral or EMS handoff plan before the patient leaves.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the referral or EMS handoff plan before the patient leaves",
          "why": "A swallowed/aspirated foreign body has real airway and GI risk even after apparent recovery; a named sign-off keeps the office from letting the patient leave without a confirmed follow-up path."
        },
        {
          "detail": "Record what was aspirated/swallowed, the response given, referral or EMS details, and outcome per DOCS/TECHNICAL_PROTOCOLS.md §8.1.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode closed",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Episode closed"
        },
        {
          "detail": "Stand behind the patient (or reposition from the chair as needed), deliver abdominal thrusts per the AHA/Red Cross adult choking algorithm, repeating until the object is expelled or the patient becomes unresponsive.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Perform abdominal thrusts"
        },
        {
          "detail": "Reassess breathing and consciousness after each cycle of thrusts.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "cleared",
              "label": "Object cleared and breathing resumed normally"
            },
            {
              "goto": "s11",
              "id": "unresponsive",
              "label": "Patient becomes unresponsive — begin CPR per the cardiac-arrest protocol (mep-004) and continue until EMS arrives"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Did the object clear, or did the patient become unresponsive?"
        },
        {
          "detail": "Give EMS a verbal summary: what was aspirated/swallowed, response given, current breathing status, and any CPR performed.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Airway obstruction, aspiration or swallowed crown, instrument or object — A crown, bur, clamp or instrument disappears into the oropharynx and the patient coughs, gags or cannot breathe — or swallows it and is breathing normally afterward.",
      "title": "Airway obstruction, aspiration or swallowed crown, instrument or object",
      "trigger": "A crown, bur, clamp or instrument disappears into the oropharynx and the patient coughs, gags or cannot breathe — or swallows it and is breathing normally afterward",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "open_standard",
          "label": "ADA office medical emergencies guidance — hypertensive crisis BP >180/120: stop treatment, call 911 if symptomatic, monitor, position upright",
          "source": "ADA office medical emergencies guidance — hypertensive crisis BP >180/120: stop treatment, call 911 if symptomatic, monitor, position upright"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mep-012",
      "kind": "clinical",
      "materials": [
        "blood pressure cuff and stethoscope (adult and large-adult cuff sizes)",
        "pulse oximeter",
        "oxygen tank and mask"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the elevated reading comes with severe headache, chest pain, shortness of breath or vision change, direct a team member to call 911 immediately before anything else.\n\nWhy: Symptomatic BP above 180/120 is a hypertensive emergency, not just an elevated number — per DOCS/TECHNICAL_PROTOCOLS.md §7.1, this combination calls 911 immediately.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Symptomatic severe hypertension: call 911 now.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Symptomatic severe hypertension: call 911 now",
          "why": "Symptomatic BP above 180/120 is a hypertensive emergency, not just an elevated number — per DOCS/TECHNICAL_PROTOCOLS.md §7.1, this combination calls 911 immediately."
        },
        {
          "detail": "Stop any active treatment, raise the chair to an upright seated position, and remove instruments from the mouth so the patient can breathe and speak freely.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Stop the procedure and reposition upright"
        },
        {
          "detail": "Ask directly and observe for distress.",
          "forks": [
            {
              "goto": "s10",
              "id": "symptomatic",
              "label": "Symptomatic — treat as a hypertensive emergency, continue toward EMS handoff"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "asymptomatic",
              "label": "Asymptomatic, reading elevated only — allow a rest period and recheck before deciding"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient symptomatic (headache, chest pain, vision change, shortness of breath)?"
        },
        {
          "detail": "Have the patient sit quietly, uninterrupted, for 10 minutes — anxiety and white-coat effect commonly inflate a single reading.",
          "id": "s4",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 600,
          "title": "Rest quietly for 10 minutes"
        },
        {
          "detail": "Recheck BP using an appropriately sized cuff on the same arm, seated, with the arm supported at heart level.\n\nWhy: An undersized cuff or unsupported arm reads falsely high — the recheck must correct for measurement technique before deciding.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Recheck blood pressure with the correct cuff size",
          "why": "An undersized cuff or unsupported arm reads falsely high — the recheck must correct for measurement technique before deciding."
        },
        {
          "detail": "Compare the recheck reading to the crisis threshold.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "normalized",
              "label": "Below threshold and patient remains asymptomatic — dentist may clear routine treatment to proceed"
            },
            {
              "goto": "s12",
              "id": "still-elevated",
              "label": "Still at or above 180/120 — do not treat today, refer for same-day medical evaluation"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Has the reading normalized below 180/120?"
        },
        {
          "detail": "Dentist documents the recheck reading and makes the explicit call: proceed with routine (non-stressful) care today, or reschedule pending medical evaluation.\n\nWhy: Whether to treat a patient with a history of an elevated reading is a clinical judgment call with real risk either way, so it gets a named sign-off rather than defaulting silently to 'proceed.'",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist clears the patient to proceed or to reschedule.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist clears the patient to proceed or to reschedule",
          "why": "Whether to treat a patient with a history of an elevated reading is a clinical judgment call with real risk either way, so it gets a named sign-off rather than defaulting silently to 'proceed.'"
        },
        {
          "detail": "Record all BP readings, symptoms, the proceed/reschedule/EMS decision, and rationale in the chart per DOCS/TECHNICAL_PROTOCOLS.md §8.1.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode closed",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Episode closed"
        },
        {
          "detail": "Apply oxygen if available, keep the patient upright and calm, and recheck BP and pulse oximetry every few minutes until EMS arrives.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Monitor vitals continuously while awaiting EMS"
        },
        {
          "detail": "Give EMS a verbal summary: BP readings and trend, symptoms reported, and any medications the patient took today.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival"
        },
        {
          "detail": "Advise the patient not to drive if severely symptomatic, and arrange same-day evaluation with their physician or urgent care rather than proceeding with dental treatment.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Refer for same-day medical evaluation"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Hypertensive crisis at pre-treatment vitals or mid-procedure — stop, position, monitor, escalate — A blood pressure reading exceeds 180/120, or a patient with very high pressure reports severe headache, chest pain or vision change.",
      "title": "Hypertensive crisis at pre-treatment vitals or mid-procedure — stop, position, monitor, escalate",
      "trigger": "A blood pressure reading exceeds 180/120, or a patient with very high pressure reports severe headache, chest pain or vision change",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "generic",
          "label": "General medical guidance on adrenal (Addisonian) crisis in steroid-dependent patients under physiologic stress — recognition and stabilization while awaiting EMS; specific stress-dose regimens are set by the patient's own prescribing physician, not this office",
          "source": "General medical guidance on adrenal (Addisonian) crisis in steroid-dependent patients under physiologic stress — recognition and stabilization while awaiting EMS; specific stress-dose regimens are set by the patient's own prescribing physician, not this office"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-013",
      "kind": "clinical",
      "materials": [
        "blood pressure cuff and stethoscope",
        "pulse oximeter",
        "glucometer",
        "oxygen tank and mask",
        "patient's own emergency stress-dose medication if brought to the visit"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Direct a team member to call 911 now and state 'possible adrenal crisis in a steroid-dependent patient, weak and hypotensive' while the team begins positioning and monitoring.\n\nWhy: Adrenal crisis can progress to cardiovascular collapse quickly and is not something the office can fully manage without emergency medical support.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 immediately",
          "why": "Adrenal crisis can progress to cardiovascular collapse quickly and is not something the office can fully manage without emergency medical support."
        },
        {
          "detail": "Recline the chair fully flat and elevate the legs to support blood pressure; loosen restrictive clothing.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Lay the patient flat with legs elevated"
        },
        {
          "detail": "Check blood pressure, pulse, pulse oximetry, and blood glucose (adrenal crisis can present with low blood sugar as well as low blood pressure).",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Take baseline vitals and blood glucose"
        },
        {
          "detail": "Ask the patient or caregiver whether they have their own physician-prescribed emergency injection or stress-dose medication with them.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "has-own-med",
              "label": "Patient has their own prescribed emergency medication — assist per the patient's own instructions"
            },
            {
              "goto": "s6",
              "id": "no-own-med",
              "label": "No patient-carried medication available — continue supportive care and wait for EMS"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient carry their own prescribed emergency stress-dose medication?"
        },
        {
          "detail": "Dentist confirms the medication is the patient's own physician-prescribed emergency stress-dose treatment, checks for any known contraindication on file, and assists administration per the instructions that came with the patient's own kit.\n\nWhy: This office does not prescribe or stock steroid stress-dose medication for patients generically — assisting with a patient's own physician-directed emergency treatment is the consequential step that needs a named clinical sign-off, distinct from administering an office-stocked drug.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms and assists with the patient's own emergency medication.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms and assists with the patient's own emergency medication",
          "why": "This office does not prescribe or stock steroid stress-dose medication for patients generically — assisting with a patient's own physician-directed emergency treatment is the consequential step that needs a named clinical sign-off, distinct from administering an office-stocked drug."
        },
        {
          "detail": "Apply oxygen by mask, and recheck blood pressure, pulse, and oximetry every few minutes while awaiting EMS.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Apply oxygen and continue monitoring"
        },
        {
          "detail": "Give EMS a verbal summary: known steroid-dependent history, vitals trend, blood glucose result, and any medication assisted.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival"
        },
        {
          "detail": "Record onset, vitals trend, blood glucose, medication assisted (if any), and EMS handoff details in the chart per DOCS/TECHNICAL_PROTOCOLS.md §8.1.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode closed",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Episode closed"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Adrenal crisis in a steroid-dependent patient — recognize, position, patient's own stress-dose, 911 — A patient on long-term corticosteroids becomes weak, hypotensive, nauseated or confused under procedural stress.",
      "title": "Adrenal crisis in a steroid-dependent patient — recognize, position, patient's own stress-dose, 911",
      "trigger": "A patient on long-term corticosteroids becomes weak, hypotensive, nauseated or confused under procedural stress",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "open_standard",
          "label": "Open anesthesia-society guidance on local anesthetic systemic toxicity (LAST) — stop injection at first symptom, secure airway with 100% oxygen, manage seizure, call for advanced help; specialized lipid-emulsion therapy is an ACLS-level intervention outside a general office's routine kit",
          "source": "Open anesthesia-society guidance on local anesthetic systemic toxicity (LAST) — stop injection at first symptom, secure airway with 100% oxygen, manage seizure, call for advanced help; specialized lipid-emulsion therapy is an ACLS-level intervention outside a general office's routine kit"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mep-014",
      "kind": "clinical",
      "materials": [
        "oxygen tank, regulator and masks",
        "BVM (bag-valve-mask)",
        "pulse oximeter",
        "AED",
        "emergency drug kit"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "At the very first sign — metallic taste, ringing in the ears, numbness around the mouth, or agitation — stop injecting immediately and direct a team member to call 911 now, stating 'possible local anesthetic toxicity.'\n\nWhy: LAST can progress from mild symptoms to seizure and cardiovascular collapse within minutes; stopping the injection and activating EMS at the earliest sign is the standard first move.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop injecting and call 911 at the first symptom.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Stop injecting and call 911 at the first symptom",
          "why": "LAST can progress from mild symptoms to seizure and cardiovascular collapse within minutes; stopping the injection and activating EMS at the earliest sign is the standard first move."
        },
        {
          "detail": "Recline the patient, ensure the airway is clear, and prepare to support breathing manually if needed.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Position and secure the airway"
        },
        {
          "detail": "Apply oxygen at the highest available concentration by mask, and monitor pulse oximetry, breathing rate and pulse continuously.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Apply 100% oxygen"
        },
        {
          "detail": "Watch for twitching progressing to convulsion.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-seizure",
              "label": "No seizure yet — continue oxygen and monitoring while awaiting EMS"
            },
            {
              "goto": "s11",
              "id": "seizing",
              "label": "Patient is seizing — protect from injury, do not restrain, keep airway open between convulsions"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Has the patient begun seizing?"
        },
        {
          "detail": "Recheck breathing, pulse, and oxygen saturation every minute; be ready to support breathing with the bag-valve-mask if breathing becomes inadequate.",
          "id": "s5",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 300,
          "title": "Monitor continuously until EMS arrives"
        },
        {
          "detail": "Reassess pulse and breathing.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "stable",
              "label": "Pulse and breathing present — continue supportive care"
            },
            {
              "goto": "s7",
              "id": "arrest",
              "label": "No pulse or not breathing normally — begin CPR and use the AED per the cardiac-arrest protocol (mep-004) until EMS arrives"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Has the patient lost pulse or stopped breathing normally?"
        },
        {
          "detail": "Dentist confirms the working diagnosis of local anesthetic systemic toxicity, tallies the total anesthetic dose given this appointment, and confirms no further local anesthetic is administered for the remainder of the visit.\n\nWhy: Confirming the diagnosis and freezing the anesthetic dose count is the consequential clinical checkpoint before handing the case to EMS — it also protects against anyone resuming the injection that caused the event.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the LAST diagnosis and total anesthetic dose for the EMS handoff.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the LAST diagnosis and total anesthetic dose for the EMS handoff",
          "why": "Confirming the diagnosis and freezing the anesthetic dose count is the consequential clinical checkpoint before handing the case to EMS — it also protects against anyone resuming the injection that caused the event."
        },
        {
          "detail": "Give EMS a verbal summary: total anesthetic dose given, time from injection to first symptom, symptoms observed including any seizure, and current status — advanced ACLS-level treatment (lipid emulsion therapy) is beyond this office's kit and belongs to responding EMS/hospital care.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival"
        },
        {
          "detail": "Record the cumulative anesthetic dose, symptom timeline, actions taken, and EMS handoff details in the chart per DOCS/TECHNICAL_PROTOCOLS.md §8.1.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode closed",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Episode closed"
        },
        {
          "detail": "Clear the area of hard or sharp objects, do not restrain the patient's movements, and reposition the airway as soon as the convulsion allows, per DOCS/TECHNICAL_PROTOCOLS.md §7.1.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Protect the seizing patient"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Local anesthetic systemic toxicity (LAST) — stop injection, airway, seizure precautions, 911 — After multiple cartridges a patient reports metallic taste, tinnitus, perioral numbness, agitation, then twitching, drowsiness, seizure or cardiovascular collapse.",
      "title": "Local anesthetic systemic toxicity (LAST) — stop injection, airway, seizure precautions, 911",
      "trigger": "After multiple cartridges a patient reports metallic taste, tinnitus, perioral numbness, agitation, then twitching, drowsiness, seizure or cardiovascular collapse",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "open_standard",
          "label": "Open public-health guidance on opioid overdose recognition and reversal — check responsiveness and breathing, support airway, administer naloxone if available, call 911; effects can wear off before the opioid does, so monitoring continues after reversal",
          "source": "Open public-health guidance on opioid overdose recognition and reversal — check responsiveness and breathing, support airway, administer naloxone if available, call 911; effects can wear off before the opioid does, so monitoring continues after reversal"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-015",
      "kind": "clinical",
      "materials": [
        "oxygen tank, regulator and masks",
        "BVM (bag-valve-mask)",
        "pulse oximeter",
        "opioid overdose reversal agent (naloxone) in the emergency kit",
        "AED"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "all-staff",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Direct a team member to call 911 now — state 'possible opioid overdose or oversedation, patient unresponsive with slow breathing' — while the team begins airway support.\n\nWhy: Reversal agents can wear off before the opioid does, so EMS transport and monitoring are needed even if the patient responds to first aid in the office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 immediately",
          "why": "Reversal agents can wear off before the opioid does, so EMS transport and monitoring are needed even if the patient responds to first aid in the office."
        },
        {
          "detail": "Tap and shout, check for normal breathing and a pulse; open and support the airway (head-tilt/chin-lift or jaw-thrust) if breathing is inadequate.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Check responsiveness, breathing and pulse"
        },
        {
          "detail": "Confirm pulse and breathing status before choosing the pathway.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "pulse-present",
              "label": "Pulse present, breathing slow/shallow — support airway and ventilate as needed, prepare reversal agent"
            },
            {
              "goto": "s9",
              "id": "no-pulse",
              "label": "No pulse — begin CPR and use the AED per the cardiac-arrest protocol (mep-004) immediately"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient have a pulse and any breathing?"
        },
        {
          "detail": "Apply oxygen and, if breathing remains inadequate, assist ventilation with the bag-valve-mask while monitoring pulse oximetry.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Support breathing with oxygen and the bag-valve-mask"
        },
        {
          "detail": "Check the emergency drug kit for the reversal agent and confirm it is not expired.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "available",
              "label": "Available and current — proceed to sign-off before administering"
            },
            {
              "goto": "s8",
              "id": "not-available",
              "label": "Not available — continue airway support and ventilation only until EMS arrives"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is an opioid overdose reversal agent (naloxone) available in the kit?"
        },
        {
          "detail": "Dentist confirms the clinical picture (slow breathing, unresponsive, pinpoint pupils, opioid exposure known or suspected) and authorizes administering the reversal agent per the kit's own labeled dose and route.\n\nWhy: Administering an emergency reversal drug is the consequential clinical step in this protocol and gets a named licensed sign-off before it happens, even in an emergency.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist authorizes administration of the reversal agent.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist authorizes administration of the reversal agent",
          "why": "Administering an emergency reversal drug is the consequential clinical step in this protocol and gets a named licensed sign-off before it happens, even in an emergency."
        },
        {
          "detail": "Administer the reversal agent per the kit's labeled dose and route, and continue supporting the airway — reversal can take a few minutes to take effect and may need to be repeated per the label if breathing does not improve.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Administer the reversal agent"
        },
        {
          "detail": "Continue oxygen, ventilation support as needed, and pulse-oximeter monitoring, reassessing at 5 minutes and every few minutes after. The reversal agent typically wears off well before the opioid does, so watch for the sedative effect returning for as long as the patient is in the office — monitoring never stops at 5 minutes and continues until EMS physically takes over.",
          "id": "s8",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 300,
          "title": "Monitor continuously — the 5-minute mark is a recheck point, not a stopping point"
        },
        {
          "detail": "Give EMS a verbal summary: sedation/medication given during the visit, onset of symptoms, reversal agent administered (dose and time) if any, and current vitals — the patient needs transport and monitoring even after apparent improvement.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to EMS on arrival"
        },
        {
          "detail": "Record sedation given, onset of symptoms, airway support and reversal agent administered, vitals trend, and EMS handoff details in the chart per DOCS/TECHNICAL_PROTOCOLS.md §8.1.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the episode"
        },
        {
          "detail": "Episode closed",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Episode closed"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Oversedation or opioid overdose — airway rescue, reversal agent, 911 — A sedated patient, or a person who took opioids before the visit, becomes unarousable with slow shallow breathing, falling oxygen saturation or pinpoint pupils.",
      "title": "Oversedation or opioid overdose — airway rescue, reversal agent, 911",
      "trigger": "A sedated patient, or a person who took opioids before the visit, becomes unarousable with slow shallow breathing, falling oxygen saturation or pinpoint pupils",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1-7.2 (in-repo emergency framework and kit list)"
        },
        {
          "kind": "generic",
          "label": "General workplace-safety first-response practice for a fall: do not move an injured person with suspected spinal or serious injury until trained help/EMS arrives; assess before assisting — a generic functional equivalent used here since the class floor does not name a fall-specific standard",
          "source": "General workplace-safety first-response practice for a fall: do not move an injured person with suspected spinal or serious injury until trained help/EMS arrives; assess before assisting — a generic functional equivalent used here since the class floor does not name a fall-specific standard"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mep-016",
      "kind": "clinical",
      "materials": [
        "blood pressure cuff and stethoscope",
        "first aid kit",
        "incident report form",
        "wheelchair or transfer aid if available"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "office-manager",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The nearest team member stays with the fallen person, asks if they are okay, and checks for responsiveness, obvious deformity, bleeding, or inability to move a limb before anyone helps them up.\n\nWhy: Moving or lifting a fallen person before assessing for a possible fracture, head injury or spinal injury can turn a minor fall into a serious one — a generic workplace-safety functional equivalent since the class floor does not name a fall-specific standard.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Do not move the person; assess responsiveness and obvious injury first",
          "why": "Moving or lifting a fallen person before assessing for a possible fracture, head injury or spinal injury can turn a minor fall into a serious one — a generic workplace-safety functional equivalent since the class floor does not name a fall-specific standard."
        },
        {
          "detail": "Look for unresponsiveness, head injury signs, inability to move a limb, severe pain, or heavy bleeding.",
          "forks": [
            {
              "goto": "s9",
              "id": "serious",
              "label": "Unresponsive or signs of serious injury — call 911, do not move the person, keep them still and warm"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "minor",
              "label": "Responsive, alert, and able to move without severe pain — proceed to careful assistance"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the person unresponsive, in severe pain, or showing signs of a serious injury?"
        },
        {
          "detail": "Offer an arm and, if a wheelchair or sturdy chair is nearby, offer it as a rest point; help the person to a seated position slowly and check for pain or dizziness before standing fully.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Assist the person up carefully"
        },
        {
          "detail": "Check blood pressure and pulse, and ask about dizziness, head strike, or new pain that may not have been obvious immediately after the fall.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Check vitals and look for delayed symptoms"
        },
        {
          "detail": "Weigh vitals and reported symptoms.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "clear",
              "label": "No injury signs, vitals normal — offer to continue the visit or reschedule by patient preference"
            },
            {
              "goto": "s10",
              "id": "delayed-symptom",
              "label": "New symptom or pain noted — advise the patient to seek medical evaluation and offer to call 911 or arrange transport"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Any sign of injury or symptom after assessment?"
        },
        {
          "detail": "Office manager reviews what happened, where, and any hazard involved (wet floor, loose mat, poor lighting, chair transfer issue) before the incident report is filed and any facility corrective action is decided.\n\nWhy: A fall is a facility-safety and potential liability event, so it gets management sign-off before being closed out — the generic functional equivalent of an incident-review step for a front-office/facility event, since no clinical licensed reviewer is required for this class of incident.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager reviews the incident before it is closed.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager reviews the incident before it is closed",
          "why": "A fall is a facility-safety and potential liability event, so it gets management sign-off before being closed out — the generic functional equivalent of an incident-review step for a front-office/facility event, since no clinical licensed reviewer is required for this class of incident."
        },
        {
          "detail": "Complete the incident report: date, time, location, what happened, injuries reported, witnesses, first aid given, and any facility corrective action assigned.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "File the incident report"
        },
        {
          "detail": "Incident closed",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Incident closed"
        },
        {
          "detail": "Direct a team member to call 911 now, give the exact location (hallway, restroom, entrance or parking area), and keep the person still and covered until EMS arrives — do not attempt to move them.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 and keep the person still.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "role": "office-manager",
          "title": "Call 911 and keep the person still"
        },
        {
          "detail": "Give EMS a verbal summary of the fall, symptoms observed, and any first aid given; if the person declines EMS but has a delayed symptom, confirm they have transport and someone to accompany them.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to EMS on arrival, or confirm transport arranged"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Patient or visitor fall in the office or parking area — assess, assist, report — A patient slips, trips or falls getting in or out of the chair, in the hallway, restroom or entrance.",
      "title": "Patient or visitor fall in the office or parking area — assess, assist, report",
      "trigger": "A patient slips, trips or falls getting in or out of the chair, in the hallway, restroom or entrance",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.2 (in-repo emergency kit list and monthly check requirement)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.2 (in-repo emergency kit list and monthly check requirement)"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 20,
      "frequency": "monthly",
      "id": "mep-017",
      "kind": "clinical",
      "materials": [
        "Emergency drug kit",
        "Oxygen tank, regulator and adult/child masks",
        "AED",
        "Blood pressure cuff and stethoscope",
        "Pulse oximeter",
        "Glucometer",
        "Kit check log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pull the emergency kit calendar reminder: first business week of each month, or immediately after any kit item is used.\n\nWhy: A monthly cadence catches expiring drugs and a low oxygen tank before an emergency, not during one.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the monthly kit-check reminder",
          "why": "A monthly cadence catches expiring drugs and a low oxygen tank before an emergency, not during one."
        },
        {
          "detail": "Check expiration dates on epinephrine autoinjector, sublingual nitroglycerin, aspirin 325mg, diphenhydramine, albuterol inhaler, oral glucose gel and ammonia inhalants; replace anything expiring before the next check.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Check emergency drug expiration dates"
        },
        {
          "detail": "Check the oxygen tank gauge reads at least 1000 PSI, the regulator and adult/child masks are present and undamaged, and the bag-valve-mask is intact.\n\nWhy: A tank found empty mid-emergency cannot be refilled in the two minutes it matters.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Check oxygen supply and airway equipment",
          "why": "A tank found empty mid-emergency cannot be refilled in the two minutes it matters."
        },
        {
          "detail": "Power on the AED self-test, confirm the pad expiration date has not passed, and confirm the battery indicator reads ready.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Run the AED self-test"
        },
        {
          "detail": "Confirm the blood pressure cuff, stethoscope, pulse oximeter and glucometer are present, functioning and within calibration per manufacturer guidance.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Check monitoring devices"
        },
        {
          "detail": "Any item missing, expired or malfunctioning?",
          "forks": [
            {
              "goto": "s9",
              "id": "yes",
              "label": "Yes — reorder or repair needed"
            },
            {
              "advised": true,
              "goto": "s7",
              "id": "no",
              "label": "No — kit complete"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Any item missing, expired or malfunctioning?"
        },
        {
          "detail": "Log the check date, checker's initials, items replaced, oxygen PSI reading and AED status on the emergency kit log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the completed check"
        },
        {
          "detail": "Monthly emergency readiness check complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Monthly emergency readiness check complete"
        },
        {
          "detail": "Place a same-week reorder for the missing or expired item and flag the kit as incomplete on the log until it is replaced.\n\nWhy: An incomplete kit is a known gap — flagging it keeps the team from assuming full readiness.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Reorder or repair the flagged item",
          "why": "An incomplete kit is a known gap — flagging it keeps the team from assuming full readiness."
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Emergency drug kit, oxygen and AED monthly check — The first week of each month, and after any use.",
      "title": "Emergency drug kit, oxygen and AED monthly check",
      "trigger": "The first week of each month, and after any use",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "url": "https://www.ada.org/resources/ada-library/oral-health-topics/medical-emergencies-in-the-dental-office"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework the drill rehearses)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework the drill rehearses)"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 35,
      "frequency": "quarterly",
      "id": "mep-018",
      "kind": "clinical",
      "materials": [
        "Emergency kit (for drill only, not consumed)",
        "AED trainer if available",
        "Scenario cards",
        "Drill log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pick an unannounced date within the quarter and select a scenario from a rotating list: syncope, anaphylaxis, cardiac arrest, choking or a new-hire orientation scenario.\n\nWhy: Unannounced timing tests real reflexes, not memorized cues.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pick an unannounced date and scenario",
          "why": "Unannounced timing tests real reflexes, not memorized cues."
        },
        {
          "detail": "Privately brief one team member to act as the affected person and simulate the chosen scenario's signs at a natural pause in the schedule.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Privately brief the actor"
        },
        {
          "detail": "The actor begins simulating the scenario in a real operatory or common area during a quiet moment; no team member outside the office manager is told in advance.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Trigger the drill unannounced"
        },
        {
          "detail": "Observe and time who called for help, who retrieved the kit and AED, who called 911 (simulated — do not actually dial), and whether roles were assigned without confusion.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Observe the team response"
        },
        {
          "detail": "Run the simulated response for up to 5 minutes or until the team reaches a stable simulated handoff point, whichever comes first.",
          "id": "s5",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 300,
          "title": "Run the simulated response window"
        },
        {
          "detail": "Did the team meet the target response window and correct sequence?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes",
              "label": "Yes — met target"
            },
            {
              "goto": "s10",
              "id": "no",
              "label": "No — gaps identified"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Did the team meet the target response window and correct sequence?"
        },
        {
          "detail": "Gather the full team within the hour for a structured debrief: what went well, what to change, and one specific action item per gap found.\n\nWhy: A drill without a debrief teaches nothing — the debrief is where the learning happens.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Hold the structured debrief",
          "why": "A drill without a debrief teaches nothing — the debrief is where the learning happens."
        },
        {
          "detail": "Log the drill date, scenario, participants, response time, gaps found and action items in the drill log for the compliance record.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the drill outcome"
        },
        {
          "detail": "Quarterly drill and debrief complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Quarterly drill and debrief complete"
        },
        {
          "detail": "Note specifically where the sequence broke down — for example delayed kit retrieval, no clear role assignment, or the AED not brought to the scene.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Note the specific gap"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Quarterly unannounced mock medical-emergency drill (syncope, anaphylaxis, cardiac arrest) and debrief — The quarterly drill is scheduled, rotating scenarios, or a new team member joins.",
      "title": "Quarterly unannounced mock medical-emergency drill (syncope, anaphylaxis, cardiac arrest) and debrief",
      "trigger": "The quarterly drill is scheduled, rotating scenarios, or a new team member joins",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016, Continuing Education Courses and Providers) and facility/equipment standards for oral conscious sedation permits (16 CCR §1044.5, Facility and Equipment Standards)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (SOAP charting standard applied to the emergency note)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (SOAP charting standard applied to the emergency note)"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "mep-019",
      "kind": "clinical",
      "materials": [
        "Chart entry template",
        "Internal incident report form",
        "Emergency contact information on file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Once EMS has departed or the event has resolved in-office, clear the area, restock or flag any kit items used, and confirm the rest of the day's schedule status.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Secure the area"
        },
        {
          "detail": "While memory is fresh, note the objective timeline: time of onset, signs observed, actions taken, vitals if recorded, time EMS was called and arrived, and outcome.\n\nWhy: Details fade within hours; the record must be written before recall degrades.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Write the objective timeline while fresh",
          "why": "Details fade within hours; the record must be written before recall degrades."
        },
        {
          "detail": "Was the patient transported by EMS, or is a caregiver not already on scene?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — notify emergency contact"
            },
            {
              "goto": "s5",
              "id": "no",
              "label": "No — contact already present or not applicable"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was the patient transported by EMS, or is a caregiver not already on scene?"
        },
        {
          "detail": "Call the patient's listed emergency contact, state the facts calmly — what happened, that EMS was called, which hospital if known — and avoid speculating on diagnosis.\n\nWhy: Only the facts belong in this call — a speculative cause spoken aloud can become a liability claim.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Call the emergency contact",
          "why": "Only the facts belong in this call — a speculative cause spoken aloud can become a liability claim."
        },
        {
          "detail": "The treating dentist reviews and personally signs the chart entry documenting the emergency before it is finalized — never left as an unsigned draft.\n\nWhy: An emergency chart note is the record a licensing board and insurer will read first; it needs the licensed provider's own signature, not just a note filed on their behalf.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating dentist signs the chart entry.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating dentist signs the chart entry",
          "why": "An emergency chart note is the record a licensing board and insurer will read first; it needs the licensed provider's own signature, not just a note filed on their behalf."
        },
        {
          "detail": "Complete the internal incident report: protocol followed, kit items used, response time, EMS run number if available, and any equipment or supply issue found.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Complete the internal incident report"
        },
        {
          "detail": "Schedule a team debrief within 24 hours — sooner if the same day is workable — covering what happened, what went well, and any gap to close.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Schedule the team debrief"
        },
        {
          "detail": "Hold the debrief: review the timeline together, invite anyone present to add what they observed, and agree on one concrete follow-up action if a gap was found.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hold the debrief"
        },
        {
          "detail": "Does the patient need a follow-up call, referral or return visit related to the event?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "yes",
              "label": "Yes — schedule follow-up"
            },
            {
              "goto": "s11",
              "id": "no",
              "label": "No follow-up needed"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient need a follow-up call, referral or return visit related to the event?"
        },
        {
          "detail": "Schedule the follow-up call or visit and note the reason in the patient's chart.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the follow-up"
        },
        {
          "detail": "File the signed chart entry, incident report and debrief notes together in the compliance record within the same business day.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the completed record set"
        },
        {
          "detail": "Post-emergency documentation and debrief cycle closed",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Post-emergency documentation and debrief cycle closed"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Post-emergency documentation, family notification and team debrief — Within one hour after any chairside medical emergency has been handed to EMS or resolved in-office.",
      "title": "Post-emergency documentation, family notification and team debrief",
      "trigger": "Within one hour after any chairside medical emergency has been handed to EMS or resolved in-office",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "regulation",
          "label": "FDA communication to industry: benzocaine oral health products carry a risk of serious, potentially fatal methemoglobinemia — OTC benzocaine teething products should not be marketed for children under 2, and new warning labeling is required on remaining benzocaine oral health products",
          "source": "FDA communication to industry: benzocaine oral health products carry a risk of serious, potentially fatal methemoglobinemia — OTC benzocaine teething products should not be marketed for children under 2, and new warning labeling is required on remaining benzocaine oral health products",
          "url": "https://www.fda.gov/files/drugs/published/FDA-Letter-Regarding-Benzocaine.pdf"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California BLS certification requirement (16 CCR §1016)",
          "source": "Dental Board of California BLS certification requirement (16 CCR §1016)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1016"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-020",
      "kind": "clinical",
      "materials": [
        "Oxygen tank, regulator and non-rebreather mask",
        "Pulse oximeter",
        "Chart entry template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Immediately call 911 and report a patient with cyanosis, a pulse oximeter reading stuck near 85% despite oxygen, and a normal airway following topical or local anesthetic use; the 911 call happens before any other step.\n\nWhy: Methemoglobinemia does not respond to more oxygen alone and needs hospital-level treatment; EMS transport must be started immediately, not after an in-office work-up.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 first — cyanosis with normal airway and low pulse-ox after anesthetic.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "assistant",
          "title": "Call 911 first — cyanosis with normal airway and low pulse-ox after anesthetic",
          "why": "Methemoglobinemia does not respond to more oxygen alone and needs hospital-level treatment; EMS transport must be started immediately, not after an in-office work-up."
        },
        {
          "detail": "Stop administering the benzocaine or prilocaine-containing product immediately and remove any remaining topical product from the mouth.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Stop the causative agent"
        },
        {
          "detail": "Apply 100% supplemental oxygen by non-rebreather mask, even though the oximeter reading will not rise as expected.\n\nWhy: Standard pulse oximeters misread methemoglobin as roughly 85% and will not correct with more oxygen — the flat reading despite oxygen is itself part of the pattern EMS needs to hear.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Apply 100% supplemental oxygen",
          "why": "Standard pulse oximeters misread methemoglobin as roughly 85% and will not correct with more oxygen — the flat reading despite oxygen is itself part of the pattern EMS needs to hear."
        },
        {
          "detail": "Monitor level of consciousness, respiratory rate, heart rate and skin color continuously until EMS arrives; note the exact time cyanosis was first observed.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Monitor continuously until EMS arrives"
        },
        {
          "detail": "The treating dentist confirms the suspected diagnosis of methemoglobinemia based on the drug exposure history and the oxygen-refractory cyanosis pattern, and directs the team to continue supportive care until EMS arrives.\n\nWhy: This is a clinical judgment call on a rare diagnosis — the licensed provider, not the assistant, owns the call on what to tell EMS and the family.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the suspected diagnosis.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the suspected diagnosis",
          "why": "This is a clinical judgment call on a rare diagnosis — the licensed provider, not the assistant, owns the call on what to tell EMS and the family."
        },
        {
          "detail": "Hand EMS the timeline, the specific product and amount used, time of onset, and the oximetry pattern observed; this history lets the receiving hospital administer the antidote quickly.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Hand EMS the exposure history and oximetry pattern"
        },
        {
          "detail": "Notify the patient's emergency contact of the transport and destination hospital if known.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Notify the emergency contact"
        },
        {
          "detail": "Document the product and lot number used, dose, time of onset, oximetry readings, vitals, actions taken and EMS run details in the chart.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the exposure and response"
        },
        {
          "detail": "Methemoglobinemia response and handoff complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Methemoglobinemia response and handoff complete"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Methemoglobinemia after benzocaine or prilocaine — A patient turns cyanotic with a normal-appearing airway and a pulse-oximeter reading stuck near 85% after topical or local anesthetic.",
      "title": "Methemoglobinemia after benzocaine or prilocaine",
      "trigger": "A patient turns cyanotic with a normal-appearing airway and a pulse-oximeter reading stuck near 85% after topical or local anesthetic",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival",
          "repaired": {
            "action": "reduce",
            "evidence": "American Heart Association CPR & ECC guidance: BLS 'addresses initial recognition of cardiac arrest, activation of emergency response, provision of high-quality cardiopulmonary resuscitation, and use of an automated external defibrillator'; for choking, 'rescuers should perform cycles of 5 back blows followed by 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive'; and AHA's 2025 update newsroom release states the guidelines 'tackle choking response, opioid-related emergencies and revised chain of survival' with 'expanded recommendations for managing choking and suspected opioid overdose.'",
            "ticket": "PROT-017",
            "was": {
              "source": "AHA Basic Life Support / ACLS guidelines and AED use (published algorithms)",
              "url": null
            }
          },
          "source": "AHA Basic Life Support / ACLS guidelines — cardiac arrest (CPR, AED use), choking/airway-obstruction response, and suspected-opioid-overdose response within the resuscitation chain of survival"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "url": "https://www.ada.org/resources/ada-library/oral-health-topics/medical-emergencies-in-the-dental-office"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework this scenario hands off into once access is gained); no public standard directly addresses locked-restroom entry, so the entry step is a generic functional equivalent",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework this scenario hands off into once access is gained); no public standard directly addresses locked-restroom entry, so the entry step is a generic functional equivalent"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "mep-021",
      "kind": "clinical",
      "materials": [
        "Door-release tool or removable-hinge access method",
        "Emergency drug kit",
        "AED"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "As soon as a restroom has been occupied longer than is normal for that person and there is no response to knocking, call 911 and report a possible person down behind a locked door; do not wait to confirm before calling.\n\nWhy: Waiting to be certain before calling 911 costs minutes when a person may be in cardiac arrest or choking on the other side of the door.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 first — restroom occupied unusually long with no response.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 first — restroom occupied unusually long with no response",
          "why": "Waiting to be certain before calling 911 costs minutes when a person may be in cardiac arrest or choking on the other side of the door."
        },
        {
          "detail": "Knock firmly and announce loudly, then listen for any response, movement or sound of distress.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Knock and announce"
        },
        {
          "detail": "Any response, movement or sound heard?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — person responds"
            },
            {
              "goto": "s6",
              "id": "no",
              "label": "No response at all"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Any response, movement or sound heard?"
        },
        {
          "detail": "Ask through the door if the person is okay and needs help; if they confirm they are fine, stand by for a reasonable interval before standing down.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the person is okay"
        },
        {
          "detail": "False alarm resolved — person confirmed okay",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "False alarm resolved — person confirmed okay"
        },
        {
          "detail": "The office manager, or the most senior staff member present, authorizes forced entry using the practice's door-release tool, removing hinge pins, or another non-destructive access method, because 911 has already been called and there is no response.\n\nWhy: Forcing a locked door is a judgment call with privacy and property consequences; naming who authorizes it keeps the decision from stalling on whether this is really okay to do.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager authorizes forced entry.",
            "role": "office manager or most senior staff present",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager authorizes forced entry",
          "why": "Forcing a locked door is a judgment call with privacy and property consequences; naming who authorizes it keeps the decision from stalling on whether this is really okay to do."
        },
        {
          "detail": "Use the practice's door-release mechanism or removable-hinge access method to open the door; if none exists, keep knocking and wait for EMS rather than damaging the door.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Gain access to the restroom"
        },
        {
          "detail": "On gaining access, check responsiveness, breathing and pulse; if unresponsive and not breathing normally, begin cardiac-arrest CPR and AED response immediately.\n\nWhy: This handoff point reaches the same universal response the cardiac-arrest protocol already covers — no need to re-derive it here.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Assess responsiveness, breathing and pulse",
          "why": "This handoff point reaches the same universal response the cardiac-arrest protocol already covers — no need to re-derive it here."
        },
        {
          "detail": "Clear other patients and visitors away from the restroom area to give EMS an unobstructed path and preserve the person's privacy.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Clear the area for EMS"
        },
        {
          "detail": "Hand EMS the timeline: when the person entered, when the office noticed, when 911 was called, and what was found on entry.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand EMS the timeline"
        },
        {
          "detail": "Log the incident: time noticed, time 911 called, entry method used, condition found, and EMS outcome, for the compliance record.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Restroom welfare-check incident closed",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Restroom welfare-check incident closed"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Person collapsed or unresponsive in a locked restroom — A restroom has been occupied unusually long and there is no response to knocking.",
      "title": "Person collapsed or unresponsive in a locked restroom",
      "trigger": "A restroom has been occupied unusually long and there is no response to knocking",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California Emergency Medical Services Authority POLST program (out-of-hospital DNR / POLST forms)",
          "source": "California Emergency Medical Services Authority POLST program (out-of-hospital DNR / POLST forms)",
          "url": "https://emsa.ca.gov/polst/"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §8.2 (informed consent documentation standard applied to the scope discussion)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.2 (informed consent documentation standard applied to the scope discussion)"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mep-022",
      "kind": "clinical",
      "materials": [
        "Copier/scanner for the form",
        "Chart flag system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "caregiver",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Receive the out-of-hospital DNR or POLST form from the patient or caregiver and make a legible copy for the chart before returning the original.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and copy the form"
        },
        {
          "detail": "Confirm the form is signed by the patient or authorized representative and a physician, is dated, and matches the state's current out-of-hospital DNR or POLST template.\n\nWhy: An expired, unsigned or wrong-state form cannot be relied on by EMS and needs to be flagged rather than treated as valid.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Verify the form is valid and current",
          "why": "An expired, unsigned or wrong-state form cannot be relied on by EMS and needs to be flagged rather than treated as valid."
        },
        {
          "detail": "Is the form valid and current?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — proceed to scope discussion"
            },
            {
              "goto": "s9",
              "id": "no",
              "label": "No — flag and request an updated form"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the form valid and current?"
        },
        {
          "detail": "The dentist reviews with the patient or caregiver exactly what the DNR or POLST covers — for example no chest compressions or intubation — and confirms in the patient's own words that the same scope should apply in the dental office, since some patients want resuscitation attempted for a reversible procedural complication even with a DNR written for a terminal illness.\n\nWhy: A DNR written for end-of-life care does not automatically answer whether the patient wants CPR attempted for a reversible in-chair complication like choking — that distinction has to be asked out loud, not assumed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm scope of care with the patient or caregiver.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm scope of care with the patient or caregiver",
          "why": "A DNR written for end-of-life care does not automatically answer whether the patient wants CPR attempted for a reversible in-chair complication like choking — that distinction has to be asked out loud, not assumed."
        },
        {
          "detail": "Write a brief chairside plan naming which interventions remain in scope — for example positioning, oxygen, calling 911 — and which are excluded per the form, and store the plan where the whole team can see it before treatment begins.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Write the chairside scope plan"
        },
        {
          "detail": "Brief the assistant and front desk on the patient's DNR or POLST status and the agreed scope before the appointment starts, without discussing it in the reception area.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Brief the team before the appointment"
        },
        {
          "detail": "File the copy of the DNR or POLST form and the documented scope discussion in the patient's chart, flagged so it is visible at every future visit.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "File the form and the scope discussion"
        },
        {
          "detail": "DNR/POLST scope clarified and documented before treatment",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "DNR/POLST scope clarified and documented before treatment"
        },
        {
          "detail": "Tell the patient or caregiver the form appears expired, unsigned or incomplete, and ask them to bring an updated copy before any sedation or elevated-risk procedure is scheduled.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag the form and request an update"
        },
        {
          "detail": "Invalid form flagged — awaiting updated documentation",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Invalid form flagged — awaiting updated documentation"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Patient with a DNR or POLST order: emergency-response plan clarified before treatment — A patient or caregiver presents an out-of-hospital DNR or POLST form.",
      "title": "Patient with a DNR or POLST order: emergency-response plan clarified before treatment",
      "trigger": "A patient or caregiver presents an out-of-hospital DNR or POLST form",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "988 Suicide & Crisis Lifeline (SAMHSA-administered public crisis line)",
          "source": "988 Suicide & Crisis Lifeline (SAMHSA-administered public crisis line)",
          "url": "https://988lifeline.org/"
        },
        {
          "kind": "open_standard",
          "label": "ADA Council on Scientific Affairs office medical emergencies guidance (open)",
          "source": "ADA Council on Scientific Affairs office medical emergencies guidance (open)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework — severity triage rule)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework — severity triage rule)"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mep-023",
      "kind": "clinical",
      "materials": [
        "988 Suicide & Crisis Lifeline number posted at front desk",
        "Referral resource list",
        "Chart entry template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the patient states an intent or plan to harm themselves, or is acutely psychotic or dissociative, call 911 immediately; if they are expressing distress without an immediate plan, contact the 988 Suicide and Crisis Lifeline together with the patient while staying with them.\n\nWhy: This event covers a spectrum from immediate danger to acute distress without a plan — 911 is for the immediate-danger end, and the entry gate has to say so plainly rather than leaving the team to guess which applies.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Assess immediate danger; call 911 or 988 for crisis support.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Assess immediate danger; call 911 or 988 for crisis support",
          "why": "This event covers a spectrum from immediate danger to acute distress without a plan — 911 is for the immediate-danger end, and the entry gate has to say so plainly rather than leaving the team to guess which applies."
        },
        {
          "detail": "Do not leave the patient alone; move them to a private, quiet area away from the open reception space if possible without restraining them.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Do not leave the patient alone"
        },
        {
          "detail": "Discreetly remove or secure sharp instruments and anything else within reach that could be used for self-harm, without making the removal obvious or alarming.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Discreetly remove hazards"
        },
        {
          "detail": "Ask directly and calmly whether the patient is thinking about harming themselves and whether they have a specific plan.\n\nWhy: The public-health evidence behind crisis-line training is that asking plainly is protective, not harmful — hedging the question wastes time in a moment where time matters.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Ask directly and calmly",
          "why": "The public-health evidence behind crisis-line training is that asking plainly is protective, not harmful — hedging the question wastes time in a moment where time matters."
        },
        {
          "detail": "Does the patient describe a specific plan or immediate danger?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "Yes — immediate danger"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "No plan, but in acute distress"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient describe a specific plan or immediate danger?"
        },
        {
          "detail": "Call 911, report a psychiatric emergency with a stated plan, and give the exact address and the patient's location within the office.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Call 911"
        },
        {
          "detail": "Keep the patient in view and calm until EMS arrives; do not leave them alone even briefly.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Stay with the patient until EMS arrives"
        },
        {
          "detail": "With the patient's agreement where possible, contact their emergency contact or caregiver about what happened and where they were taken or referred.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify the emergency contact"
        },
        {
          "detail": "The treating dentist reviews and signs the chart note documenting what was said, what was done, and the outcome, in behavioral terms only — no diagnostic labeling beyond what the patient stated.\n\nWhy: This chart entry needs the same licensed sign-off as any other clinical incident note, and it needs to record only what was observed and said, not an unlicensed diagnosis.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the behavioral chart note.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the behavioral chart note",
          "why": "This chart entry needs the same licensed sign-off as any other clinical incident note, and it needs to record only what was observed and said, not an unlicensed diagnosis."
        },
        {
          "detail": "File the chart note and, if EMS or a mandated report was involved, the incident report, in the compliance record.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "File the note and any report"
        },
        {
          "detail": "Mental-health crisis response and follow-up documented",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Mental-health crisis response and follow-up documented"
        },
        {
          "detail": "Call or connect the patient to the 988 Suicide and Crisis Lifeline from the office and stay with the patient through the call.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Call the 988 crisis line"
        },
        {
          "detail": "After the 988 call, does the presentation now indicate immediate danger?",
          "forks": [
            {
              "advised": false,
              "goto": "s6",
              "id": "yes",
              "label": "Yes — escalate to 911"
            },
            {
              "advised": true,
              "goto": "s14",
              "id": "no",
              "label": "No — arrange safe follow-up"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "dentist",
          "title": "After the 988 call, does the presentation now indicate immediate danger?"
        },
        {
          "detail": "Arrange for the patient to leave with a trusted person, or wait with staff until one arrives, and give them the 988 number and a referral resource before they leave.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Arrange safe follow-up"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Patient expresses suicidal ideation or an acute mental-health crisis — A patient says they intend to harm themselves, or becomes acutely psychotic or dissociative in the office.",
      "title": "Patient expresses suicidal ideation or an acute mental-health crisis",
      "trigger": "A patient says they intend to harm themselves, or becomes acutely psychotic or dissociative in the office",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Government Code §27491 (coroner jurisdiction over deaths, including those on business premises)",
          "source": "California Government Code §27491 (coroner jurisdiction over deaths, including those on business premises)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=27491&lawCode=GOV"
        },
        {
          "kind": "open_standard",
          "label": "AHA Basic Life Support / ACLS guidelines (defines when resuscitation has been appropriately stopped)",
          "source": "AHA Basic Life Support / ACLS guidelines (defines when resuscitation has been appropriately stopped)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework this incident follows on from)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7.1 (in-repo emergency response framework this incident follows on from)"
        }
      ],
      "class": "medical-emergency-preparedness",
      "department": "emergency",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "mep-024",
      "kind": "clinical",
      "materials": [
        "Incident report form",
        "Legal counsel and malpractice carrier contact information",
        "Employee counseling resource list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "office-manager",
        "compliance-officer",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If EMS has not yet been called, call 911 immediately; if resuscitation has already been stopped by EMS or a person is found without signs of life, do not resume care outside EMS or coroner direction — confirm EMS involvement is already underway before anything else happens.\n\nWhy: Even once death is apparent, the office does not have authority to declare it — that determination and the scene handling both belong to EMS and the coroner, so the gate exists to confirm they are already engaged, not to skip calling them.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm EMS is on scene or call 911 immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm EMS is on scene or call 911 immediately",
          "why": "Even once death is apparent, the office does not have authority to declare it — that determination and the scene handling both belong to EMS and the coroner, so the gate exists to confirm they are already engaged, not to skip calling them."
        },
        {
          "detail": "Do not move the body, clean the area, or alter anything at the scene; close the operatory or area and keep it exactly as EMS left it until the coroner's office releases it.\n\nWhy: Scene preservation is a legal requirement once a death has occurred on premises — cleaning up, even with good intentions, can be read as tampering.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Preserve the scene",
          "why": "Scene preservation is a legal requirement once a death has occurred on premises — cleaning up, even with good intentions, can be read as tampering."
        },
        {
          "detail": "Move other patients and visitors to a separate area out of view of the scene, and pause new check-ins for the rest of the day if the schedule allows.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Move others away from the scene"
        },
        {
          "detail": "Notify the practice owner immediately by phone, regardless of the hour.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the practice owner"
        },
        {
          "detail": "Confirm EMS has notified the coroner's office as required for an on-premises death, or make that notification directly if EMS has not.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm coroner notification"
        },
        {
          "detail": "Coordinate with EMS or the coroner's office on who notifies the family and when — the practice does not make first notification to the family on its own unless EMS or the coroner explicitly asks it to.\n\nWhy: Death notification has a specific, trained protocol that EMS and coroner personnel follow; the practice inserting itself first can cause real harm and legal exposure, so this gate routes the decision through the people trained for it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Coordinate family notification through EMS/coroner.",
            "role": "practice owner, coordinating with EMS/coroner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Coordinate family notification through EMS/coroner",
          "why": "Death notification has a specific, trained protocol that EMS and coroner personnel follow; the practice inserting itself first can cause real harm and legal exposure, so this gate routes the decision through the people trained for it."
        },
        {
          "detail": "Offer any team member present at the scene the option to leave for the day, and arrange coverage for their remaining appointments.\n\nWhy: Witnessing a death is traumatic; forcing someone to keep working the same shift is not a neutral choice.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Offer staff support",
          "why": "Witnessing a death is traumatic; forcing someone to keep working the same shift is not a neutral choice."
        },
        {
          "detail": "No team member speaks to media, posts on social media, or discusses the event outside the practice; all outside inquiries are directed to the practice owner or legal counsel only.\n\nWhy: An offhand comment from anyone other than the designated spokesperson can create liability the practice cannot walk back.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route all outside inquiries to one spokesperson.",
            "role": "practice owner or designated spokesperson",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Route all outside inquiries to one spokesperson",
          "why": "An offhand comment from anyone other than the designated spokesperson can create liability the practice cannot walk back."
        },
        {
          "detail": "Contact the practice's malpractice carrier and legal counsel before any internal report is finalized or shared outside the immediate leadership team.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Contact carrier and counsel before finalizing any report.",
            "role": "compliance officer, with legal counsel",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Contact carrier and counsel before finalizing any report"
        },
        {
          "detail": "Document the full timeline: last known status before the event, actions taken, time EMS was called and arrived, time of scene release by the coroner, and every person present, for the compliance and insurance record.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the full timeline"
        },
        {
          "detail": "Schedule a full-team debrief once EMS and coroner processes are underway, focused on support and factual review rather than blame, and offer access to counseling resources to anyone who was present.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Schedule the team debrief and support"
        },
        {
          "detail": "File the incident report, coroner case number if issued, and legal counsel's guidance together in the compliance record.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the closing record set"
        },
        {
          "detail": "Death-on-premises response, notification and support process closed",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Death-on-premises response, notification and support process closed"
        }
      ],
      "subclass": "medical-emergencies-at-the-chair",
      "summary": "Death on the premises: scene preservation, coroner, family and team support — Resuscitation is stopped by EMS in the office, or a person is found dead on site.",
      "title": "Death on the premises: scene preservation, coroner, family and team support",
      "trigger": "Resuscitation is stopped by EMS in the office, or a person is found dead on site",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "source": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "url": "https://www.ecfr.gov/current/title-16/part-465"
        },
        {
          "kind": "open_standard",
          "label": "No ADA/disability-accessibility authority governs NAP listing consistency; treat as a local-SEO/directory-data-hygiene practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No ADA/disability-accessibility authority governs NAP listing consistency; treat as a local-SEO/directory-data-hygiene practice — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Same ADA Title III/WCAG material confirmed for key 32e1f46ef657fe1b: it governs screen-reader/alt-text/keyboard-navigation website accessibility for people with disabilities. It says nothing about business-listing accuracy, NAP consistency, or directory data across Google/Yelp/etc., which is mkt-001's actual subject.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III web accessibility; WCAG 2.x (open standard)",
              "url": null
            }
          },
          "source": "No ADA/disability-accessibility authority governs NAP listing consistency; treat as a local-SEO/directory-data-hygiene practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 25,
      "frequency": "weekly",
      "id": "mkt-001",
      "kind": "compliance",
      "materials": [
        "listing tracker (spreadsheet or dashboard)",
        "current practice NAP (name, address, phone) source of truth",
        "current hours, holiday closures",
        "screenshots folder for before/after"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Open the practice's canonical record of name, address, phone, and current posted hours (including any temporary holiday closures) before checking any external listing.\n\nWhy: A comparison is only as good as the reference it is checked against; checking listings against each other instead of the source of truth lets errors propagate.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Pull the current source-of-truth NAP and hours",
          "why": "A comparison is only as good as the reference it is checked against; checking listings against each other instead of the source of truth lets errors propagate."
        },
        {
          "detail": "Open each business listing profile (search engine business profile, map listing, directory listings, social profile 'about' pages, website footer and contact page) and compare name spelling, suite/unit number, phone number format, and posted hours against the source of truth.\n\nWhy: Inconsistent NAP across listings is a known ranking and patient-trust signal problem; each listing is checked individually because platforms do not sync automatically.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Check each major listing against the source of truth",
          "why": "Inconsistent NAP across listings is a known ranking and patient-trust signal problem; each listing is checked individually because platforms do not sync automatically."
        },
        {
          "detail": "Any discrepancy found?",
          "forks": [
            {
              "advised": false,
              "goto": "s10",
              "id": "none",
              "label": "No discrepancies — all listings match"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "found",
              "label": "One or more discrepancies found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "marketing",
          "title": "Any discrepancy found?"
        },
        {
          "detail": "Log into the listing platform's own management console and edit the field(s) that do not match the source of truth. Take a before screenshot and an after screenshot.\n\nWhy: Screenshots create a record for the metrics log and protect against a platform silently reverting the edit.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Correct the listing directly on the platform",
          "why": "Screenshots create a record for the metrics log and protect against a platform silently reverting the edit."
        },
        {
          "detail": "Some platforms apply edits instantly; others queue changes for manual review that can take days. Record the expected delay next to the correction.\n\nWhy: Setting the right expectation avoids re-flagging the same item as still-wrong before the platform has actually applied it.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Note the platform's review/propagation delay",
          "why": "Setting the right expectation avoids re-flagging the same item as still-wrong before the platform has actually applied it."
        },
        {
          "detail": "Did a patient report this discrepancy?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes-patient",
              "label": "Yes, a patient reported it"
            },
            {
              "advised": false,
              "goto": "s8",
              "id": "no-patient",
              "label": "No, found during routine check"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "marketing",
          "title": "Did a patient report this discrepancy?"
        },
        {
          "detail": "Send front desk a short note naming which platform showed wrong info and what the corrected info is, so they can reassure a patient who calls back confused.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Notify front desk the listed info was wrong and is now fixed"
        },
        {
          "detail": "Write the correction into the listing tracker with the before/after screenshots attached.\n\nRecord: Date, platform, field corrected, old value, new value, before/after screenshot location, expected propagation delay.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Log the correction"
        },
        {
          "detail": "Weekly check complete — correction(s) logged",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Weekly check complete — correction(s) logged"
        },
        {
          "detail": "Write the clean-check result into the listing tracker so this week's check is on record.\n\nRecord: Date checked, listings reviewed, result: no discrepancies.",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Log a clean check"
        },
        {
          "detail": "Weekly check complete — no action needed",
          "id": "s11",
          "kind": "step",
          "role": "marketing",
          "title": "Weekly check complete — no action needed"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Weekly business listing and name/address/phone consistency check — The weekly check day arrives, or a patient reports a wrong phone number or hours online.",
      "title": "Weekly business listing and name/address/phone consistency check",
      "trigger": "The weekly check day arrives, or a patient reports a wrong phone number or hours online",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "source": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.508"
        },
        {
          "kind": "regulation",
          "label": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "source": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "url": "https://www.ecfr.gov/current/title-16/part-465"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mkt-002",
      "kind": "compliance",
      "materials": [
        "approved response templates",
        "review-monitoring dashboard or alerts",
        "HIPAA marketing/PHI reference sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "A review-monitoring alert or manual check surfaces a new public review, positive or negative, on any platform the practice is listed on.\n\nWhy: Timely awareness is the precondition for a timely, on-brand response.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "New review detected",
          "why": "Timely awareness is the precondition for a timely, on-brand response."
        },
        {
          "detail": "Before any reply is drafted, confirm the responder understands the rule: never confirm, deny, or restate that the reviewer was a patient, and never reference any treatment, procedure, diagnosis, date of visit, or billing detail — even if the reviewer disclosed it themselves.\n\nWhy: HIPAA's Privacy Rule constrains the covered entity's own disclosures regardless of what the patient chose to post publicly; the practice cannot 'confirm' the relationship or add clinical detail.",
          "gate": {
            "ack": "I confirm I have completed this step as written: PHI disclosure gate before drafting a response.",
            "role": "compliance-officer or trained office-manager",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "PHI disclosure gate before drafting a response",
          "why": "HIPAA's Privacy Rule constrains the covered entity's own disclosures regardless of what the patient chose to post publicly; the practice cannot 'confirm' the relationship or add clinical detail."
        },
        {
          "detail": "Is the review positive/neutral or negative?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "positive",
              "label": "Positive or neutral review"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "negative",
              "label": "Negative review (1-2 stars) or viral/spreading post"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the review positive/neutral or negative?"
        },
        {
          "detail": "Use an approved template: thank the reviewer generically, invite them to reach out directly with any questions, and never repeat specifics they mentioned (procedure names, staff names tied to treatment, cost figures).\n\nWhy: A generic template reduces the chance of an ad-lib response accidentally restating PHI back into a public thread.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Draft a generic, PHI-free thank-you response",
          "why": "A generic template reduces the chance of an ad-lib response accidentally restating PHI back into a public thread."
        },
        {
          "detail": "A second set of eyes reads the draft specifically checking for any name, date, procedure, or dollar figure that should not be there.\n\nWhy: A second reviewer catches what the drafter, close to the review, may not notice.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Manager reviews the drafted response before posting",
          "why": "A second reviewer catches what the drafter, close to the review, may not notice."
        },
        {
          "detail": "Publish the approved response using the practice's authorized account on that platform.",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Post the response on the platform"
        },
        {
          "detail": "Write the review and the posted response into the review-monitoring dashboard.\n\nRecord: Platform, date, star rating, response posted, responder, PHI-check confirmed.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Log the review and response"
        },
        {
          "detail": "Response posted and logged",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Response posted and logged"
        },
        {
          "detail": "Negative or viral reviews route to mkt-003 (negative or viral review escalation and service recovery) instead of continuing this routine path.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the negative-review escalation protocol"
        },
        {
          "detail": "Routed to negative-review escalation protocol",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Routed to negative-review escalation protocol"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Responding to an online review without confirming or disclosing patient information — A new public review is posted, including one naming a visit, procedure or bill.",
      "title": "Responding to an online review without confirming or disclosing patient information",
      "trigger": "A new public review is posted, including one naming a visit, procedure or bill",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "source": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.508"
        },
        {
          "kind": "regulation",
          "label": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "source": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "url": "https://www.ecfr.gov/current/title-16/part-465"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "mkt-003",
      "kind": "compliance",
      "materials": [
        "escalation tracker",
        "service-recovery offer guidelines",
        "PHI-safe response templates",
        "internal contact log to check for a related complaint"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "marketing",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "A 1-2 star review, a post being shared or quoted by others, or a review naming a specific complaint (billing dispute, wait time, treatment outcome) is flagged for escalation rather than the routine response path.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Negative or viral post identified"
        },
        {
          "detail": "Send the review link, screenshot, and platform to the office manager and practice owner the same day it is found.\n\nWhy: Negative and viral content compounds with delay; same-day awareness lets the practice respond before the thread grows.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Notify office manager and practice owner immediately",
          "why": "Negative and viral content compounds with delay; same-day awareness lets the practice respond before the thread grows."
        },
        {
          "detail": "Search the front-desk complaint log and any prior patient correspondence for a matching name, date, or issue described in the post, without posting any of what is found publicly.\n\nWhy: Understanding what actually happened internally lets the practice craft an honest, non-defensive public response and decide whether direct outreach is warranted.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Check internal records for a matching complaint or incident",
          "why": "Understanding what actually happened internally lets the practice craft an honest, non-defensive public response and decide whether direct outreach is warranted."
        },
        {
          "detail": "Confirm no planned response — public or via direct message — will confirm the person as a patient or state any treatment, diagnosis, or billing detail, even to correct a factual error the reviewer stated incorrectly.\n\nWhy: The urge to correct a public factual error is strong, but correcting it would itself be a PHI disclosure; the practice must respond only in general terms.",
          "gate": {
            "ack": "I confirm I have completed this step as written: PHI disclosure gate before any public or direct reply.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "PHI disclosure gate before any public or direct reply",
          "why": "The urge to correct a public factual error is strong, but correcting it would itself be a PHI disclosure; the practice must respond only in general terms."
        },
        {
          "detail": "Acknowledge the reviewer's experience generically, apologize for any dissatisfaction without admitting fault or detail, and invite them to contact the practice directly to resolve it.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft a public, empathetic, PHI-free response"
        },
        {
          "detail": "The practice owner reviews and approves the exact wording of the public response and any service-recovery offer (refund, redo, credit) before either is extended.\n\nWhy: A negative/viral situation carries reputational and sometimes financial exposure that belongs at the owner level, not delegated silently.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off on public response and any recovery offer.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off on public response and any recovery offer",
          "why": "A negative/viral situation carries reputational and sometimes financial exposure that belongs at the owner level, not delegated silently."
        },
        {
          "detail": "Publish the approved public response, and if contact information is available and the reviewer is a known patient, reach out privately (phone or secure message) to offer to resolve the issue.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Post the public response and attempt direct outreach"
        },
        {
          "detail": "Extend a service-recovery offer?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "offer",
              "label": "Extend an approved recovery offer (refund, redo, credit)"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "no-offer",
              "label": "No recovery offer warranted after investigation"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Extend a service-recovery offer?"
        },
        {
          "detail": "Write the offer and its outcome into the escalation tracker for follow-up monitoring.\n\nRecord: Date, reviewer contact method, offer extended, patient response, resolution status.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the recovery offer and outcome"
        },
        {
          "detail": "Check over the following two weeks whether the reviewer updates or removes the review, or whether the thread continues to spread.",
          "id": "s10",
          "kind": "timer",
          "role": "marketing",
          "timer_seconds": 1209600,
          "title": "Monitor for a follow-up or updated review"
        },
        {
          "detail": "Escalation and service-recovery cycle complete",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Escalation and service-recovery cycle complete"
        },
        {
          "detail": "Write the no-offer decision and its reasoning into the escalation tracker for the record.\n\nRecord: Date, investigation summary (internal only, no PHI in the marketing log), reason no offer was extended.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the decision and reasoning"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Negative or viral review escalation and service recovery — A one- or two-star review is posted, or a post about the practice is spreading, tagged or quoted by others.",
      "title": "Negative or viral review escalation and service recovery",
      "trigger": "A one- or two-star review is posted, or a post about the practice is spreading, tagged or quoted by others",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "source": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "url": "https://www.ecfr.gov/current/title-16/part-465"
        },
        {
          "kind": "statute",
          "label": "California B&P §651 (health care advertising), §650 (referral compensation), §1680 (dental advertising); AB 3030 for GenAI patient-facing clinical content",
          "source": "California B&P §651 (health care advertising), §650 (referral compensation), §1680 (dental advertising); AB 3030 for GenAI patient-facing clinical content"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 90,
      "frequency": "monthly",
      "id": "mkt-004",
      "kind": "compliance",
      "materials": [
        "content calendar tool or spreadsheet",
        "prior month's performance notes",
        "seasonal/clinical topic list",
        "brand voice and claims guidelines"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Look at which website pages, social posts, and email sends from the prior month got the most engagement, and which topics have not been covered recently.\n\nWhy: Planning from what worked and what is stale avoids repeating low-performing content out of habit.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Review prior month's content performance",
          "why": "Planning from what worked and what is stale avoids repeating low-performing content out of habit."
        },
        {
          "detail": "Draft a list covering website blog/education topics, social post themes, and email newsletter topics for the coming month, noting any seasonal or practice-specific events (new provider, expanded hours, community event).",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "List candidate topics across channels"
        },
        {
          "detail": "Does any planned topic include a clinical statement, before/after image, or health claim?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clinical-yes",
              "label": "Yes — one or more topics include clinical statements or claims"
            },
            {
              "advised": false,
              "goto": "s5",
              "id": "clinical-no",
              "label": "No — general practice/lifestyle content only"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "marketing",
          "title": "Does any planned topic include a clinical statement, before/after image, or health claim?"
        },
        {
          "detail": "Mark these calendar items so that when drafted, they route through mkt-006 (AI-generated marketing content review) and mkt-010 (advertising claim and specialty review) before publication.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Flag clinical-topic items for the AI-content and advertising-claim review protocols"
        },
        {
          "detail": "Assign each piece a target publish date, channel, draft owner, and review status column (draft, in review, approved, published).",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Build the calendar grid with dates, channel, owner, and status"
        },
        {
          "detail": "For any piece drafted with an AI tool that will reach patients, plan to carry the disclosure 'AI-generated — reviewed by a licensed provider' where the content includes clinical information, per California AB 3030.\n\nWhy: Building the disclosure into the plan up front avoids a scramble to add it at publish time.",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Note AB 3030 disclosure requirement for any AI-drafted patient-facing content",
          "why": "Building the disclosure into the plan up front avoids a scramble to add it at publish time."
        },
        {
          "detail": "Share the draft calendar with the dentist(s) and office manager for topic input, corrections, and awareness of what is coming.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Circulate the draft calendar for practice input"
        },
        {
          "detail": "Save the finalized calendar grid into the content tracker as the month's plan of record.\n\nRecord: Final calendar grid with dates, channels, owners, clinical-flag items, and AI-disclosure notes, saved in the content tracker.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Finalize and save the month's calendar"
        },
        {
          "detail": "Monthly content calendar finalized",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Monthly content calendar finalized"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Monthly content calendar (website, social, email) — The month begins and the next month of website, social and email content is planned.",
      "title": "Monthly content calendar (website, social, email)",
      "trigger": "The month begins and the next month of website, social and email content is planned",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "source": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.508"
        },
        {
          "kind": "statute",
          "label": "California B&P §651 (health care advertising), §650 (referral compensation), §1680 (dental advertising); AB 3030 for GenAI patient-facing clinical content",
          "source": "California B&P §651 (health care advertising), §650 (referral compensation), §1680 (dental advertising); AB 3030 for GenAI patient-facing clinical content"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mkt-005",
      "kind": "compliance",
      "materials": [
        "written HIPAA marketing authorization form",
        "photo/video release form",
        "de-identification checklist",
        "secure storage location for signed authorizations",
        "minor-patient status field (from the patient record)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "front-desk",
        "dentist",
        "compliance-officer",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Marketing or the dentist identifies a specific patient photo, video, before/after image, or testimonial quote as a candidate for the website or social media.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "A patient case, photo, or testimonial is selected for marketing use"
        },
        {
          "detail": "Confirm the practice has (or will obtain) a specific, written HIPAA marketing authorization naming the exact use (which platform, how long, whether it can be reused) before approaching the patient — verbal or implied consent is not sufficient.\n\nWhy: HIPAA's marketing rule requires a written, specific authorization separate from general treatment consent; using PHI for marketing without it is a compliance violation regardless of good intent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Written authorization required before any request is made to the patient.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Written authorization required before any request is made to the patient",
          "why": "HIPAA's marketing rule requires a written, specific authorization separate from general treatment consent; using PHI for marketing without it is a compliance violation regardless of good intent."
        },
        {
          "detail": "Check the patient record for date of birth to determine whether the patient is under the age of majority in the practice's state before deciding who signs the authorization.\n\nWhy: A HIPAA marketing authorization for a minor patient must be signed by the parent or legal guardian, not the child; pediatric before/after and orthodontic cases are common marketing candidates, so this branch is not an edge case.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "adult",
              "label": "Patient is an adult"
            },
            {
              "advised": false,
              "goto": "s12",
              "id": "minor",
              "label": "Patient is a minor"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the patient a minor?",
          "why": "A HIPAA marketing authorization for a minor patient must be signed by the parent or legal guardian, not the child; pediatric before/after and orthodontic cases are common marketing candidates, so this branch is not an edge case."
        },
        {
          "detail": "Explain in plain language exactly what will be used (which photo, what caption, which platforms) and for how long, and give the patient the form to read before signing.\n\nWhy: A patient who understands exactly what they are authorizing can give informed consent and is less likely to later dispute the use.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Present the authorization form to the patient and explain the specific use",
          "why": "A patient who understands exactly what they are authorizing can give informed consent and is less likely to later dispute the use."
        },
        {
          "detail": "Does the patient sign the authorization?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "signs",
              "label": "Patient signs the authorization"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "declines",
              "label": "Patient declines"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient sign the authorization?"
        },
        {
          "detail": "The dentist reviews any before/after image or testimonial claim for clinical accuracy before it is used in marketing.\n\nWhy: A treating clinician confirms the content does not overstate or misrepresent the outcome shown.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews the content for clinical accuracy and appropriateness",
          "why": "A treating clinician confirms the content does not overstate or misrepresent the outcome shown."
        },
        {
          "detail": "Confirm: the authorized platforms match where the content will actually be posted; no unintended identifying detail (background items, other patients, staff badges, appointment cards) is visible in the frame; the authorization's time window has not expired; and any caption stays within what was authorized.\n\nWhy: A signed authorization only covers what it actually says — using the same photo on a new platform or after expiration is a fresh, unauthorized use.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "De-identification and scope check",
          "why": "A signed authorization only covers what it actually says — using the same photo on a new platform or after expiration is a fresh, unauthorized use."
        },
        {
          "detail": "Post the approved content only to the platforms and for the duration named in the signed authorization.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Publish the content on the authorized platform(s)"
        },
        {
          "detail": "File the signed authorization in secure storage and record its scope in the authorization log.\n\nRecord: Patient identifier reference (per practice PHI-on-device policy), signing party (patient, or parent/guardian and relationship if the patient is a minor), content description, platforms authorized, authorization date, expiration, signed form stored securely.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log and securely store the authorization"
        },
        {
          "detail": "Keep the authorization record accessible so that if the patient later revokes consent, marketing can locate and remove the content promptly.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Track for a possible future revocation request"
        },
        {
          "detail": "Content authorized, published, and logged",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Content authorized, published, and logged"
        },
        {
          "detail": "Explain in plain language exactly what will be used (which photo, what caption, which platforms) and for how long, and give the parent or legal guardian of record the form to read before signing on the minor patient's behalf.\n\nWhy: The parent or legal guardian, not the minor patient, is the legally authorized signer for a HIPAA marketing authorization involving a minor.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Present the authorization form to the parent or guardian and explain the specific use",
          "why": "The parent or legal guardian, not the minor patient, is the legally authorized signer for a HIPAA marketing authorization involving a minor."
        },
        {
          "detail": "Does the parent or guardian sign the authorization?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "signs",
              "label": "Parent or guardian signs the authorization"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "declines",
              "label": "Parent or guardian declines"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "caregiver",
          "title": "Does the parent or guardian sign the authorization?"
        },
        {
          "detail": "Patient declined — content not used",
          "id": "s14",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient declined — content not used"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Patient photo, video, testimonial or before/after image authorization and de-identification check before any use — The practice wants to publish patient content, or marketing selects a clinical case for the website or social media.",
      "title": "Patient photo, video, testimonial or before/after image authorization and de-identification check before any use",
      "trigger": "The practice wants to publish patient content, or marketing selects a clinical case for the website or social media",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California B&P §651 (health care advertising), §650 (referral compensation), §1680 (dental advertising); AB 3030 for GenAI patient-facing clinical content",
          "source": "California B&P §651 (health care advertising), §650 (referral compensation), §1680 (dental advertising); AB 3030 for GenAI patient-facing clinical content"
        },
        {
          "kind": "regulation",
          "label": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "source": "FTC Act §5; Endorsement Guides 16 CFR Part 255; Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "url": "https://www.ecfr.gov/current/title-16/part-465"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "mkt-006",
      "kind": "compliance",
      "materials": [
        "AI-drafted content piece",
        "advertising-claim checklist",
        "AB 3030 disclosure text",
        "brand voice guidelines"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Marketing submits the AI-drafted blog post, ad copy, page content, or social caption into the review queue before any publication.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "AI-drafted content submitted for review"
        },
        {
          "detail": "Does the content include clinical statements, health claims, or patient-facing instructions?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "clinical-yes",
              "label": "Yes — contains clinical statements or claims"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "clinical-no",
              "label": "No — general practice information only (hours, staff bios, community news)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "marketing",
          "title": "Does the content include clinical statements, health claims, or patient-facing instructions?"
        },
        {
          "detail": "The dentist reads the AI-drafted content line by line and confirms every clinical statement is accurate, not overstated, and does not create an implied guarantee or diagnosis of the reader.\n\nWhy: AB 3030 requires GenAI-generated patient-facing clinical communications to carry a provider-reviewed exemption path — the review must actually happen, not just be claimed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider reviews every clinical statement.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider reviews every clinical statement",
          "why": "AB 3030 requires GenAI-generated patient-facing clinical communications to carry a provider-reviewed exemption path — the review must actually happen, not just be claimed."
        },
        {
          "detail": "Per AB 3030, for any piece that reaches a patient with clinical content, add the disclosure: 'AI-generated — reviewed by a licensed provider,' placed where a reader will see it before acting on the content.\n\nWhy: AB 3030 (H&S §1339.75) attaches to GenAI-generated patient-facing clinical communications and carries a provider-reviewed exemption — the disclosure and the review together satisfy it; SB 1120 does not apply here because it governs insurer utilization review, not practice marketing.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Add the AB 3030 AI-generation disclosure where required",
          "why": "AB 3030 (H&S §1339.75) attaches to GenAI-generated patient-facing clinical communications and carries a provider-reviewed exemption — the disclosure and the review together satisfy it; SB 1120 does not apply here because it governs insurer utilization review, not practice marketing."
        },
        {
          "detail": "Hand the reviewed draft to the advertising claim and specialty review protocol (mkt-010) to check superiority, guarantee, and credential language before it is published.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Route to advertising-claim review before publishing"
        },
        {
          "detail": "Approved to publish?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "approved",
              "label": "Approved — publish as reviewed"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "returned",
              "label": "Returned for correction"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Approved to publish?"
        },
        {
          "detail": "Publish the content with any required AI-disclosure text intact.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Publish the approved content"
        },
        {
          "detail": "Write the review outcome and disclosure status into the content review log.\n\nRecord: Content title, reviewer(s), clinical-content flag, disclosure applied (yes/no), publication date.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the review"
        },
        {
          "detail": "AI-generated content reviewed and published",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "AI-generated content reviewed and published"
        },
        {
          "detail": "A marketing lead reads the non-clinical draft for tone, factual accuracy (hours, names, dates), and brand consistency.",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Marketing lead reviews for brand voice and factual accuracy"
        },
        {
          "detail": "Send the draft back to whoever is editing it with the specific line(s) that need correction, and route it back through this review before it can publish.",
          "id": "s11",
          "kind": "step",
          "role": "marketing",
          "title": "Return the draft with specific correction notes"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "AI-generated marketing content review before publication (clinical statements dentist-reviewed) — A blog post, ad, page or social caption was drafted with an AI tool.",
      "title": "AI-generated marketing content review before publication (clinical statements dentist-reviewed)",
      "trigger": "A blog post, ad, page or social caption was drafted with an AI tool",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200; CAN-SPAM 16 CFR Part 316",
          "source": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200; CAN-SPAM 16 CFR Part 316",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        },
        {
          "kind": "regulation",
          "label": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "source": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.508"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mkt-007",
      "kind": "compliance",
      "materials": [
        "CAN-SPAM pre-send checklist",
        "email platform with unsubscribe management",
        "practice's physical mailing address for the footer",
        "recipient/consent list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "The content, subject line, and recipient list are assembled and staged in the email platform.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Newsletter or promotional email draft is ready to send"
        },
        {
          "detail": "Confirm the 'From' name and address accurately identify the practice, the subject line is not deceptive about the content, and the email is clearly identifiable as coming from the practice.\n\nWhy: CAN-SPAM requires accurate header and routing information and prohibits deceptive subject lines.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Header and identification check",
          "why": "CAN-SPAM requires accurate header and routing information and prohibits deceptive subject lines."
        },
        {
          "detail": "Confirm the email includes the practice's valid physical postal address and a clear, working unsubscribe mechanism that will be honored.\n\nWhy: CAN-SPAM requires a valid physical address and a functioning opt-out mechanism in every commercial email.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Footer and unsubscribe check",
          "why": "CAN-SPAM requires a valid physical address and a functioning opt-out mechanism in every commercial email."
        },
        {
          "detail": "Read the draft to confirm no treatment detail, diagnosis, appointment specifics, or billing information about any individual patient appears in the body text.\n\nWhy: A mass newsletter is not the place for any patient-specific clinical or billing content, even generalized examples that could be read as describing a real patient.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Scan the email body for PHI",
          "why": "A mass newsletter is not the place for any patient-specific clinical or billing content, even generalized examples that could be read as describing a real patient."
        },
        {
          "detail": "Cross-check the send list against the current opt-out/do-not-contact list before sending, per mkt-009.\n\nWhy: CAN-SPAM and prior opt-outs must be honored on every send, not just checked once when the list was built.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Confirm the recipient list reflects current consent and opt-outs",
          "why": "CAN-SPAM and prior opt-outs must be honored on every send, not just checked once when the list was built."
        },
        {
          "detail": "Does the draft pass all checks?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pass",
              "label": "Passes all checks"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "fail",
              "label": "One or more checks fail"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "marketing",
          "title": "Does the draft pass all checks?"
        },
        {
          "detail": "Send the newsletter or promotional email through the approved platform.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Send the email"
        },
        {
          "detail": "Write the send details into the email platform's campaign log for tracking.\n\nRecord: Send date, subject line, recipient count, checklist completion, any bounces/unsubscribes tracked post-send.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Log the send"
        },
        {
          "detail": "Email sent and logged",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Email sent and logged"
        },
        {
          "detail": "Correct the header, footer, PHI, or list issue found, then return to the header check step.",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Fix the failing item and re-run the checklist"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Email newsletter send — header, identification, unsubscribe, no PHI — A newsletter or promotional email is about to be sent.",
      "title": "Email newsletter send — header, identification, unsubscribe, no PHI",
      "trigger": "A newsletter or promotional email is about to be sent",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200; CAN-SPAM 16 CFR Part 316",
          "source": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200; CAN-SPAM 16 CFR Part 316",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mkt-008",
      "kind": "compliance",
      "materials": [
        "consent capture form (intake paperwork or digital form)",
        "texting/calling platform with consent-status field",
        "opt-out/do-not-contact list",
        "campaign send checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "marketing",
        "it-vendor",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "A new or returning patient provides a mobile number during intake, scheduling, or an update to their contact information.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient provides a mobile number"
        },
        {
          "detail": "Check the patient record for minor status. If the patient is a minor, confirm whether the number belongs to the parent/guardian of record or to the minor directly (e.g. a teen's own phone), since consent for marketing contact tied to a minor is captured from the parent or guardian.\n\nWhy: TCPA consent tied to a minor patient's contact information should be attributable to the parent/guardian of record, not the minor, for the same reason a HIPAA marketing authorization for a minor requires a guardian signature.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "adult-own-number",
              "label": "Adult patient, patient's own number"
            },
            {
              "advised": false,
              "goto": "s3",
              "id": "minor-guardian-number",
              "label": "Patient is a minor — capture consent from the parent/guardian of record"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the patient a minor, and whose number is this?",
          "why": "TCPA consent tied to a minor patient's contact information should be attributable to the parent/guardian of record, not the minor, for the same reason a HIPAA marketing authorization for a minor requires a guardian signature."
        },
        {
          "detail": "Ask the consenting party (the patient, or the parent/guardian of record if the patient is a minor) directly whether they consent to receive appointment-related texts/calls and, separately, whether they consent to receive promotional/marketing texts/calls, and record each answer distinctly — these are legally separate consents under the TCPA.\n\nWhy: The TCPA and FCC rules require prior express consent for automated texts/calls, and marketing messages require a higher standard (prior express written consent) than purely informational appointment reminders.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Capture prior express consent before enrolling the number for texts/calls.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "front-desk",
          "title": "Capture prior express consent before enrolling the number for texts/calls",
          "why": "The TCPA and FCC rules require prior express consent for automated texts/calls, and marketing messages require a higher standard (prior express written consent) than purely informational appointment reminders."
        },
        {
          "detail": "Enter both consent answers into the platform's consent-status field so campaigns can filter on them later.\n\nRecord: Mobile number, consenting party (patient, or parent/guardian and relationship if the patient is a minor), appointment-reminder consent (yes/no), marketing/promotional consent (yes/no), date captured, method (in-person form, digital form, verbal with written follow-up).",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Record consent status in the contact platform"
        },
        {
          "detail": "Is a promotional text/call campaign being planned that would use this list?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "campaign-yes",
              "label": "Yes — a promotional campaign is planned"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "campaign-no",
              "label": "No campaign right now — consent capture only"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "marketing",
          "title": "Is a promotional text/call campaign being planned that would use this list?"
        },
        {
          "detail": "Pull only the numbers with marketing/promotional consent recorded as yes, excluding numbers with only appointment-reminder consent and excluding anyone on the opt-out/do-not-contact list.\n\nWhy: Sending a promotional message to a number that only consented to appointment reminders is a separate TCPA violation from sending to a number with no consent at all.",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Filter the campaign send list to marketing-consented numbers only",
          "why": "Sending a promotional message to a number that only consented to appointment reminders is a separate TCPA violation from sending to a number with no consent at all."
        },
        {
          "detail": "Compliance officer confirms the filtered list only includes marketing-consented, non-opted-out numbers, and that the message includes required identification and an opt-out instruction (e.g., reply STOP).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before the campaign sends.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before the campaign sends"
        },
        {
          "detail": "Execute the send through the practice's texting/calling platform, using the filtered and approved list.",
          "id": "s8",
          "kind": "step",
          "role": "it-vendor",
          "title": "Send the campaign through the approved platform"
        },
        {
          "detail": "Write the campaign send details into the campaign tracker with the compliance sign-off attached.\n\nRecord: Campaign name, send date, list size, consent-filter confirmed, compliance sign-off recorded.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Log the campaign send"
        },
        {
          "detail": "Campaign sent to consented list and logged",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Campaign sent to consented list and logged"
        },
        {
          "detail": "Consent captured and recorded — no campaign at this time",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Consent captured and recorded — no campaign at this time"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Capturing prior express consent for texts and calls, written consent for marketing messages, and the campaign send check — A new patient provides a mobile number, or the practice launches a promotional text campaign.",
      "title": "Capturing prior express consent for texts and calls, written consent for marketing messages, and the campaign send check",
      "trigger": "A new patient provides a mobile number, or the practice launches a promotional text campaign",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200",
          "source": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        },
        {
          "kind": "regulation",
          "label": "CAN-SPAM Act 16 CFR Part 316",
          "source": "CAN-SPAM Act 16 CFR Part 316",
          "url": "https://www.ecfr.gov/current/title-16/part-316"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "mkt-009",
      "kind": "compliance",
      "materials": [
        "text/email platform admin console",
        "patient contact preference field in the practice management system",
        "do-not-contact log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "marketing",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Treat any of these as an opt-out: a text reply of STOP, UNSUBSCRIBE, CANCEL, END, or QUIT; an email unsubscribe click; a verbal 'stop contacting me' or 'take me off your list' on a call; or a written note.\n\nWhy: TCPA and CAN-SPAM treat any clear request to stop as revocation of consent, regardless of the exact wording or channel used.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Recognize the opt-out signal",
          "why": "TCPA and CAN-SPAM treat any clear request to stop as revocation of consent, regardless of the exact wording or channel used."
        },
        {
          "detail": "Never ask the patient to call, log in, or explain why before honoring the request. Acknowledge and process immediately.\n\nWhy: Regulations prohibit making opt-out unreasonably difficult; requiring extra steps is itself a violation.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Do not require a reason or additional steps",
          "why": "Regulations prohibit making opt-out unreasonably difficult; requiring extra steps is itself a violation."
        },
        {
          "detail": "A STOP reply to a text campaign legally suppresses only that texting number/channel unless the patient says 'all contact' or similar.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "o1",
              "label": "Patient said 'all contact' / 'stop everything'"
            },
            {
              "goto": "s9",
              "id": "o2",
              "label": "Patient opted out of one channel only (e.g. texts)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "marketing",
          "title": "Which channel(s) does the request cover?"
        },
        {
          "detail": "In the practice management system and any connected texting/email platform, set marketing contact preference to do-not-contact for text, email, and outbound promotional calls. Leave clinical/appointment-reminder channels the patient has separately consented to untouched unless they said to stop those too.\n\nWhy: A blanket request must be honored across systems, not just the one channel where it arrived.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Suppress every marketing channel for the patient",
          "why": "A blanket request must be honored across systems, not just the one channel where it arrived."
        },
        {
          "detail": "If the practice uses more than one platform for text, email and calling, verify the do-not-contact flag syncs to all of them, not just the one where the request landed.\n\nWhy: A generic functional equivalent of any multi-platform marketing stack: unsynced suppression lists are the most common repeat-contact failure mode.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Propagate suppression to every connected list",
          "why": "A generic functional equivalent of any multi-platform marketing stack: unsynced suppression lists are the most common repeat-contact failure mode."
        },
        {
          "detail": "Date, channel, patient identifier, and which contact types were suppressed, in the do-not-contact log.\n\nRecord: Date, channel, patient identifier, and which contact types were suppressed, in the do-not-contact log.",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Log the opt-out"
        },
        {
          "detail": "At the next weekly or monthly campaign send, confirm the patient was excluded from the send list before it went out.",
          "id": "s7",
          "kind": "timer",
          "role": "marketing",
          "timer_seconds": 604800,
          "title": "Verify suppression held through the next scheduled campaign"
        },
        {
          "detail": "Opt-out processed and verified",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Opt-out processed and verified"
        },
        {
          "detail": "Flag only the channel named (e.g. texting) as do-not-contact; leave email or mail marketing active unless separately opted out.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Suppress the specific channel"
        },
        {
          "detail": "If the request is unclear (e.g. 'stop texting me so much'), send a one-time neutral confirmation on the same channel asking whether to stop entirely or just reduce frequency — never a second promotional message.",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Confirm scope with the patient if ambiguous"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "STOP, opt-out and do-not-contact request processing across channels — A patient replies STOP, unsubscribes, or asks not to be called.",
      "title": "STOP, opt-out and do-not-contact request processing across channels",
      "trigger": "A patient replies STOP, unsubscribes, or asks not to be called",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Act §5 (unfair or deceptive acts or practices)",
          "source": "FTC Act §5 (unfair or deceptive acts or practices)"
        },
        {
          "kind": "regulation",
          "label": "FTC Endorsement Guides 16 CFR Part 255",
          "source": "FTC Endorsement Guides 16 CFR Part 255",
          "url": "https://www.ecfr.gov/current/title-16/part-255"
        },
        {
          "kind": "statute",
          "label": "California B&P §651 (health care advertising) and §1680 (dental advertising)",
          "source": "California B&P §651 (health care advertising) and §1680 (dental advertising)"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mkt-010",
      "kind": "compliance",
      "materials": [
        "draft ad or page copy",
        "advertising claim review checklist",
        "state dental board advertising rule reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "dentist",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Copy the full text, images and any pricing/offer language of the ad, page or post into the review checklist before it is scheduled or published.\n\nWhy: Nothing goes live without passing through this checklist first — reviewing after publication is too late for advertising claims.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Pull the draft into the review checklist",
          "why": "Nothing goes live without passing through this checklist first — reviewing after publication is too late for advertising claims."
        },
        {
          "detail": "Flag any use of 'best', '#1', 'guaranteed', 'pain-free', 'no risk', or claims of a specific outcome; flag any claim of being board-certified in a specialty area unless the dentist actually holds that board certification.\n\nWhy: Unsubstantiated superiority claims and false specialty/credential claims are the most commonly cited advertising violations under FTC and state dental board rules.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Scan for superiority, guarantee and outcome claims",
          "why": "Unsubstantiated superiority claims and false specialty/credential claims are the most commonly cited advertising violations under FTC and state dental board rules."
        },
        {
          "detail": "Does the ad include pricing, a discount, or a before/after image?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "o1",
              "label": "Yes — pricing, discount, or before/after present"
            },
            {
              "goto": "s5",
              "id": "o2",
              "label": "No pricing or images to check"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the ad include pricing, a discount, or a before/after image?"
        },
        {
          "detail": "Confirm any listed price is currently accurate and any expiration/exclusion terms are stated plainly; confirm before/after images have a signed patient authorization on file per the photo-authorization protocol and are not stock or composite images presented as real cases.\n\nWhy: Misleading pricing and unauthorized or fabricated before/after images are both direct consumer-protection and dental-board exposure.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify pricing terms and image sourcing",
          "why": "Misleading pricing and unauthorized or fabricated before/after images are both direct consumer-protection and dental-board exposure."
        },
        {
          "detail": "The dentist reviews and initials any statement describing a technique, technology, credential, or specialty area named in the ad.\n\nWhy: A licensed clinician, not marketing staff, is the only person positioned to confirm a clinical or credential claim is true.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm any clinical or credential statement is accurate",
          "why": "A licensed clinician, not marketing staff, is the only person positioned to confirm a clinical or credential claim is true."
        },
        {
          "detail": "The ad does not go live, and is not scheduled, until a licensed dentist has signed off on the reviewed and revised copy. A non-dentist practice owner may add a separate business sign-off, but that never substitutes for the clinician's licensed sign-off on clinical or credential claims.\n\nWhy: Non-negotiable HITL boundary: advertising claims with clinical or credential content never auto-publish, and the licensed-signoff gate exists specifically to keep clinical/credential accuracy with someone who actually holds the license — business ownership is not a substitute for clinical licensure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off before publication.",
            "role": "dentist (or another licensed treating clinician) — never a non-clinician practice owner acting alone",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off before publication",
          "why": "Non-negotiable HITL boundary: advertising claims with clinical or credential content never auto-publish, and the licensed-signoff gate exists specifically to keep clinical/credential accuracy with someone who actually holds the license — business ownership is not a substitute for clinical licensure."
        },
        {
          "detail": "Final approved copy, reviewer names, and date, kept with the ad for as long as it runs plus the state's advertising record-retention period if longer.\n\nRecord: Final approved copy, reviewer names, and date, kept with the ad for as long as it runs plus the state's advertising record-retention period if longer.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Log the reviewed and approved version"
        },
        {
          "detail": "Approved copy is handed to whoever schedules or places the ad, with the sign-off record attached.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Hand off to publish"
        },
        {
          "detail": "Ad cleared for publication",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Ad cleared for publication"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Advertising copy review — superiority, guarantee, specialty and credential claims, pricing, before/after — A new ad, website page, signage or social post is drafted.",
      "title": "Advertising copy review — superiority, guarantee, specialty and credential claims, pricing, before/after",
      "trigger": "A new ad, website page, signage or social post is drafted",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Act §5 (unfair or deceptive acts or practices)",
          "source": "FTC Act §5 (unfair or deceptive acts or practices)",
          "url": "https://www.ftc.gov/legal-library/browse/statutes/federal-trade-commission-act"
        },
        {
          "kind": "statute",
          "label": "California B&P §650 (referral compensation) and §651 (health care advertising)",
          "source": "California B&P §650 (referral compensation) and §651 (health care advertising)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=650.&lawCode=BPC"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "mkt-011",
      "kind": "compliance",
      "materials": [
        "promotion offer draft",
        "fee schedule",
        "insurance participation list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "billing",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Write the offer including exact price or discount amount, what is and is not included, and an expiration date or condition.\n\nWhy: An offer without stated boundaries invites a dispute at checkout, which is where most promotion complaints originate.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Draft the offer with explicit terms",
          "why": "An offer without stated boundaries invites a dispute at checkout, which is where most promotion complaints originate."
        },
        {
          "detail": "Confirm the discounted or promotional price is still above cost and consistent with the practice's published fee schedule for the same service outside the promotion.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Check the offer against the current fee schedule"
        },
        {
          "detail": "Does the offer apply to patients with dental insurance?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "o1",
              "label": "Offer applies only to uninsured/self-pay patients"
            },
            {
              "goto": "s9",
              "id": "o2",
              "label": "Offer is open to insured patients too"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the offer apply to patients with dental insurance?"
        },
        {
          "detail": "Add 'for patients without dental insurance' or equivalent language directly in the ad, not only in fine print.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "State the self-pay-only condition in the offer copy"
        },
        {
          "detail": "Any print, social, or digital placement of the offer carries the expiration date and a short list of exclusions (e.g. 'not valid with other offers', 'new patients only').",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Post the exclusions and expiration where the offer is seen"
        },
        {
          "detail": "Give front desk and billing a one-line summary of who qualifies and what is included so the promotion is applied consistently at the counter.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Brief front desk on how to apply the offer at checkout"
        },
        {
          "detail": "Offer text, price, exclusions, expiration, and channels used, kept for the life of the promotion plus the practice's record-retention period.\n\nRecord: Offer text, price, exclusions, expiration, and channels used, kept for the life of the promotion plus the practice's record-retention period.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Log the offer and its terms"
        },
        {
          "detail": "Promotion approved and ready to run",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Promotion approved and ready to run"
        },
        {
          "detail": "Confirm the promotion does not waive a copay or deductible in a way that misrepresents the fee to the insurer, and does not function as a kickback for referrals.\n\nWhy: Routinely waiving patient cost-share can constitute insurance fraud in some states and is a recurring dental-board and payer audit finding.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check for insurance-interplay issues",
          "why": "Routinely waiving patient cost-share can constitute insurance fraud in some states and is a recurring dental-board and payer audit finding."
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Promotion, fee, discount and free-exam offer disclosures, expiration terms and insurance interplay — A new-patient special or discount offer is planned.",
      "title": "Promotion, fee, discount and free-exam offer disclosures, expiration terms and insurance interplay",
      "trigger": "A new-patient special or discount offer is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "source": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.508"
        },
        {
          "kind": "regulation",
          "label": "HIPAA definition of marketing 45 CFR 164.501",
          "source": "HIPAA definition of marketing 45 CFR 164.501",
          "url": "https://www.ecfr.gov/current/title-45/section-164.501"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mkt-012",
      "kind": "compliance",
      "materials": [
        "HIPAA marketing authorization form",
        "notice of privacy practices",
        "vendor/product description"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "HIPAA marketing rules exempt communications about the patient's own treatment, case management, and the practice's own similar health-related products/services made without third-party payment; communications promoting a third-party's product or paid for by a third party require patient authorization.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "o1",
              "label": "Third-party product/service, or third party paid for the communication"
            },
            {
              "goto": "s9",
              "id": "o2",
              "label": "Practice's own treatment-related or exempt communication"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is this communication about the practice's own treatment, or a third-party paid product?"
        },
        {
          "detail": "Determine the patient list that would receive the communication, using only the minimum PHI necessary to identify eligible patients.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify which patients would be contacted"
        },
        {
          "detail": "Draft an authorization describing exactly what PHI will be used, the purpose, the third party involved if any, and an expiration date, per the HIPAA marketing authorization requirements.\n\nWhy: A blanket or vague authorization does not meet the specificity HIPAA requires for a marketing use of PHI.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Prepare a specific authorization request",
          "why": "A blanket or vague authorization does not meet the specificity HIPAA requires for a marketing use of PHI."
        },
        {
          "detail": "The authorization form and the underlying use of PHI are reviewed against 45 CFR 164.508 before being sent to any patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews the authorization before any patient is asked to sign.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews the authorization before any patient is asked to sign"
        },
        {
          "detail": "Send or present the authorization to each affected patient and wait for a signed return before including that patient in the marketing communication.\n\nWhy: Non-negotiable: PHI is never used for a third-party marketing purpose without the specific patient's own signed authorization.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Obtain the signed authorization from each patient before contacting them",
          "why": "Non-negotiable: PHI is never used for a third-party marketing purpose without the specific patient's own signed authorization."
        },
        {
          "detail": "Patient identifier, date signed, scope, and expiration of the authorization, retained per the practice's HIPAA record-retention schedule.\n\nRecord: Patient identifier, date signed, scope, and expiration of the authorization, retained per the practice's HIPAA record-retention schedule.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log each signed authorization"
        },
        {
          "detail": "Cross-check the final send list against the signed-authorization log before the message goes out; exclude anyone without a current signed authorization or who has revoked it.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Send the communication only to authorized patients"
        },
        {
          "detail": "Communication sent within HIPAA marketing authorization requirements",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Communication sent within HIPAA marketing authorization requirements"
        },
        {
          "detail": "Send the treatment-related or exempt communication through normal patient communication channels; note in the record why it was exempt.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Proceed without a marketing authorization"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "HIPAA authorization before using PHI for marketing or third-party promotions — A vendor or the practice wants to message patients about a paid product or service outside treatment communications.",
      "title": "HIPAA authorization before using PHI for marketing or third-party promotions",
      "trigger": "A vendor or the practice wants to message patients about a paid product or service outside treatment communications",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "source": "FTC Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "url": "https://www.ecfr.gov/current/title-16/part-465"
        },
        {
          "kind": "regulation",
          "label": "FTC Endorsement Guides 16 CFR Part 255",
          "source": "FTC Endorsement Guides 16 CFR Part 255",
          "url": "https://www.ecfr.gov/current/title-16/part-255"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mkt-013",
      "kind": "compliance",
      "materials": [
        "review request template/tool",
        "review platform links"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Every patient who completes a visit receives the identical review request with links to the same review platforms — never a request sent only to patients believed to be happy, and never a request withheld from a patient with a complaint.\n\nWhy: Selectively asking only satisfied-seeming patients (gating) is exactly the deceptive practice the FTC rule targets, even without an explicit filter step.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the same review request to every patient",
          "why": "Selectively asking only satisfied-seeming patients (gating) is exactly the deceptive practice the FTC rule targets, even without an explicit filter step."
        },
        {
          "detail": "Is a gift, discount, or incentive being proposed for leaving a review?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "No incentive planned"
            },
            {
              "goto": "s6",
              "id": "o2",
              "label": "Someone proposed a gift/discount for a review"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is a gift, discount, or incentive being proposed for leaving a review?"
        },
        {
          "detail": "A published review or testimonial must reflect the reviewer's own words and honest opinion; do not fabricate reviews or materially edit a quote to remove a criticism while keeping the praise.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Never write, edit, or select which portions of a testimonial to publish in a way that changes its meaning"
        },
        {
          "detail": "Do not publish or solicit reviews from staff, family members, or anyone who was not actually a patient, presented as an independent patient review.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Confirm every published reviewer is a real patient"
        },
        {
          "detail": "Review solicitation and use meets ungated, unincentivized, authentic-content rules",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Review solicitation and use meets ungated, unincentivized, authentic-content rules"
        },
        {
          "detail": "Do not offer anything of value conditioned on leaving a review, or conditioned on the review being positive. A reward for simply visiting the practice (unrelated to reviewing) is a different, permitted category.\n\nWhy: Compensated reviews without clear and conspicuous disclosure, and any incentive conditioned on a positive review, are banned outright under the FTC rule.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Reject or restructure the incentive",
          "why": "Compensated reviews without clear and conspicuous disclosure, and any incentive conditioned on a positive review, are banned outright under the FTC rule."
        },
        {
          "detail": "The original proposal and the compliant alternative, if any, kept with the marketing decision log.\n\nRecord: The original proposal and the compliant alternative, if any, kept with the marketing decision log.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document why the incentive was rejected or how it was restructured"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Soliciting reviews and testimonials without gating, incentives or fabricated content — the same ask goes to everyone — The practice sets up a post-visit review request, or a staff member proposes offering a gift for reviews.",
      "title": "Soliciting reviews and testimonials without gating, incentives or fabricated content — the same ask goes to everyone",
      "trigger": "The practice sets up a post-visit review request, or a staff member proposes offering a gift for reviews",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California B&P §650 (prohibition on fee-splitting/referral compensation for health care referrals)",
          "source": "California B&P §650 (prohibition on fee-splitting/referral compensation for health care referrals)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=650.&lawCode=BPC"
        },
        {
          "kind": "regulation",
          "label": "FTC Act §5 (unfair or deceptive acts or practices, as applied to undisclosed referral incentives)",
          "source": "FTC Act §5 (unfair or deceptive acts or practices, as applied to undisclosed referral incentives)",
          "url": "https://www.ftc.gov/legal-library/browse/statutes/federal-trade-commission-act"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mkt-014",
      "kind": "compliance",
      "materials": [
        "proposed referral program terms",
        "state dental board referral-fee rule reference",
        "state insurance anti-kickback rule reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "marketing",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Write down exactly who qualifies to refer, what the referred patient must do (e.g. complete a first visit) for the reward to trigger, the reward amount/form, and any caps.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Draft the proposed program terms"
        },
        {
          "detail": "Does the reward go to a patient, or to another business/referral source (e.g. a physician office)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "o1",
              "label": "Reward goes to patients referring other patients"
            },
            {
              "goto": "s7",
              "id": "o2",
              "label": "Reward or payment would go to another licensed professional or business for referrals"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the reward go to a patient, or to another business/referral source (e.g. a physician office)?"
        },
        {
          "detail": "Most states permit modest patient-to-patient referral rewards (e.g. account credit) if disclosed and not tied to insurance billing manipulation; confirm the reward is not structured as a kickback for using insurance benefits in a way that inflates billing.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check patient-to-patient referral rewards against state consumer/advertising rules"
        },
        {
          "detail": "Set a reasonable per-referral and per-year cap, and require that any referral reward be disclosed in program materials rather than handled informally.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm disclosure and cap terms"
        },
        {
          "detail": "Program terms, the legal-review determination, caps, and approval date.\n\nRecord: Program terms, the legal-review determination, caps, and approval date.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the review outcome"
        },
        {
          "detail": "Referral program cleared to launch",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Referral program cleared to launch"
        },
        {
          "detail": "Paying another licensed health professional or business for patient referrals is prohibited or tightly restricted in most states and can implicate anti-kickback and fee-splitting statutes; do not launch this form of the program without a documented legal review.\n\nWhy: Non-negotiable: referral compensation to other professionals is one of the highest-risk categories in dental board and insurance-fraud enforcement.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop — professional-to-professional referral payment requires legal review before launch.",
            "role": "compliance officer / outside counsel",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Stop — professional-to-professional referral payment requires legal review before launch",
          "why": "Non-negotiable: referral compensation to other professionals is one of the highest-risk categories in dental board and insurance-fraud enforcement."
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Patient referral reward program legality check (state referral-fee and anti-kickback rules) — The practice wants to give credits or gifts for patient referrals.",
      "title": "Patient referral reward program legality check (state referral-fee and anti-kickback rules)",
      "trigger": "The practice wants to give credits or gifts for patient referrals",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR Part 160 and Part 164 Subpart E (unauthorized disclosure of PHI)",
          "source": "HIPAA Privacy Rule 45 CFR Part 160 and Part 164 Subpart E (unauthorized disclosure of PHI)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Breach Notification Rule 45 CFR §§164.400-414 Subpart D (four-factor risk-of-compromise assessment §164.402; 60-day outer notification deadline §164.404(b))",
          "source": "HIPAA Breach Notification Rule 45 CFR §§164.400-414 Subpart D (four-factor risk-of-compromise assessment §164.402; 60-day outer notification deadline §164.404(b))",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-D"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "mkt-015",
      "kind": "compliance",
      "materials": [
        "staff social media policy",
        "screenshot/archive of the post",
        "HR incident file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Report the post and its link to the office manager or compliance officer as soon as it is noticed — do not wait, comment on it, or ask the poster to take it down informally first.\n\nWhy: Every minute the post is live increases exposure; an informal ask can also alert the poster to delete evidence before it is documented.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Anyone who spots the post reports it immediately",
          "why": "Every minute the post is live increases exposure; an informal ask can also alert the poster to delete evidence before it is documented."
        },
        {
          "detail": "Screenshot the post, caption, comments and any visible identifying detail (patient face, chart screen, x-ray, appointment book, name tag) with timestamp, before it is removed.\n\nWhy: The post may need to be assessed for a HIPAA breach-notification obligation, which requires knowing exactly what was exposed.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Preserve evidence of the post before requesting takedown",
          "why": "The post may need to be assessed for a HIPAA breach-notification obligation, which requires knowing exactly what was exposed."
        },
        {
          "detail": "Does the post show identifiable patient information (face, name, chart, x-ray) or clinical/schedule detail?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "o1",
              "label": "Yes — identifiable patient information is visible"
            },
            {
              "goto": "s9",
              "id": "o2",
              "label": "No — operatory/office only, no patient identifiable"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the post show identifiable patient information (face, name, chart, x-ray) or clinical/schedule detail?"
        },
        {
          "detail": "Treat this as a potential HIPAA breach: run the Breach Notification Rule's four-factor risk-of-compromise test (45 CFR §164.402 — nature/extent of the PHI involved, who saw or acquired it, whether it was actually viewed or acquired, and the extent the risk was mitigated) to decide whether this is a reportable breach; if it is, notification to the affected patient(s) is due no later than 60 days after discovery (45 CFR §164.404(b)).\n\nWhy: An unauthorized PHI disclosure on social media is evaluated the same way any other unauthorized disclosure is, under the practice's breach-assessment process and the same four-factor test and 60-day clock the Breach Notification Rule sets for any other channel.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer opens a potential-breach assessment.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer opens a potential-breach assessment",
          "why": "An unauthorized PHI disclosure on social media is evaluated the same way any other unauthorized disclosure is, under the practice's breach-assessment process and the same four-factor test and 60-day clock the Breach Notification Rule sets for any other channel."
        },
        {
          "detail": "Ask the staff member to delete the post immediately and confirm deletion; also request takedown from the platform directly if the poster is unresponsive.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Request immediate takedown"
        },
        {
          "detail": "HR opens a personnel file entry and applies the disciplinary step defined in the staff social media policy, up to and including termination for a serious or repeat exposure.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Hand off to HR for the personnel side"
        },
        {
          "detail": "Date, what was posted, breach-assessment outcome, takedown confirmation, and HR action taken, in the compliance incident log.\n\nRecord: Date, what was posted, breach-assessment outcome, takedown confirmation, and HR action taken, in the compliance incident log.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident and its resolution"
        },
        {
          "detail": "Incident resolved and documented",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Incident resolved and documented"
        },
        {
          "detail": "Remind the staff member of the social media policy and confirm they understand what counts as identifiable patient information even without a face visible (e.g. an appointment book, a chart on a monitor).",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Handle as a policy reminder, not a breach"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Staff social media policy and incident response (patient photo, operatory selfie) — A team member posts content from the office that may show a patient or chart.",
      "title": "Staff social media policy and incident response (patient photo, operatory selfie)",
      "trigger": "A team member posts content from the office that may show a patient or chart",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Act §5 (unfair or deceptive acts or practices, as applied to undisclosed tracking)",
          "source": "FTC Act §5 (unfair or deceptive acts or practices, as applied to undisclosed tracking)"
        },
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule 45 CFR Part 160 and Part 164 (tracking technologies guidance context)",
          "source": "HIPAA Privacy Rule 45 CFR Part 160 and Part 164 (tracking technologies guidance context)"
        },
        {
          "kind": "regulation",
          "label": "FTC Health Breach Notification Rule 16 CFR Part 318 (notification duty for unauthorized third-party disclosure of health information, including by tracking technologies, that falls outside HIPAA's covered-entity boundary)",
          "source": "FTC Health Breach Notification Rule 16 CFR Part 318 (notification duty for unauthorized third-party disclosure of health information, including by tracking technologies, that falls outside HIPAA's covered-entity boundary)",
          "url": "https://www.ecfr.gov/current/title-16/part-318"
        },
        {
          "kind": "open_standard",
          "label": "No ADA/disability-accessibility authority governs a privacy-notice/tracking-pixel/form-data review; treat as an internal data-privacy control (session-replay/pixel disclosure, form-data handling) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No ADA/disability-accessibility authority governs a privacy-notice/tracking-pixel/form-data review; treat as an internal data-privacy control (session-replay/pixel disclosure, form-data handling) — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Searched 'ADA Title III web accessibility WCAG dental website lawsuit' and confirmed via ADA Title III material that it governs screen-reader/alt-text/keyboard-navigation accessibility for people with disabilities. Nothing in that body of law addresses tracking pixels, privacy notices, or form-data collection — mkt-016's actual subject is a data-privacy/tracking matter, not a disability-access one, and no single authority in scope for this packet covers it.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Title III web accessibility; WCAG 2.x",
              "url": null
            }
          },
          "source": "No ADA/disability-accessibility authority governs a privacy-notice/tracking-pixel/form-data review; treat as an internal data-privacy control (session-replay/pixel disclosure, form-data handling) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 45,
      "frequency": "annual",
      "id": "mkt-016",
      "kind": "compliance",
      "materials": [
        "website privacy notice",
        "list of installed tracking scripts/pixels",
        "contact/intake form fields"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "List every analytics tag, advertising pixel, chat widget, and third-party embed currently running on the site, and which pages each one loads on.\n\nWhy: A privacy notice can only be accurate if it is checked against what is actually installed, not what was installed when the notice was last written.",
          "id": "s1",
          "kind": "step",
          "role": "it-vendor",
          "title": "Inventory every tracking script and pixel on the website",
          "why": "A privacy notice can only be accurate if it is checked against what is actually installed, not what was installed when the notice was last written."
        },
        {
          "detail": "Flag any analytics or advertising pixel installed on the appointment-request, contact, or intake page where a visitor might describe symptoms, procedures, or insurance details.\n\nWhy: A tracking pixel that captures form-field content on a health-related page can transmit sensitive health information to a third-party ad or analytics platform without the visitor's knowledge.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Identify any tracking script present on a page with a health-related form",
          "why": "A tracking pixel that captures form-field content on a health-related page can transmit sensitive health information to a third-party ad or analytics platform without the visitor's knowledge."
        },
        {
          "detail": "For any tracking script flagged on a health-related form page, determine whether it shared visitor health information with a third party (ad network, analytics platform) without the visitor's authorization — this can trigger a notification duty under the FTC Health Breach Notification Rule (16 CFR Part 318) even when the practice's public marketing pages fall outside HIPAA's covered-entity boundary.\n\nWhy: The public website is frequently not itself a HIPAA-covered transaction, but 16 CFR Part 318 reaches undisclosed sharing of health-related information gathered through consumer-facing tools like website forms and trackers, independent of HIPAA.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Assess FTC Health Breach Notification Rule exposure separately from HIPAA",
          "why": "The public website is frequently not itself a HIPAA-covered transaction, but 16 CFR Part 318 reaches undisclosed sharing of health-related information gathered through consumer-facing tools like website forms and trackers, independent of HIPAA."
        },
        {
          "detail": "Is a tracking script present on a health-related form page?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "o1",
              "label": "Yes — remove or reconfigure it"
            },
            {
              "goto": "s6",
              "id": "o2",
              "label": "No tracking on health-related form pages"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is a tracking script present on a health-related form page?"
        },
        {
          "detail": "Either remove the third-party script from the intake/contact page entirely, or configure it so it does not capture form field values, before the page goes back live.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Remove the pixel from that page or block it from reading form content"
        },
        {
          "detail": "List each category of tracking technology in use (analytics, advertising, chat) in plain language in the website privacy notice, and how a visitor can decline where technically possible (e.g. a cookie banner).",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Update the privacy notice to match what is actually installed"
        },
        {
          "detail": "Confirm the form does not request unnecessary sensitive information (e.g. detailed symptom description) when a simpler field would do, and that submitted data routes only to the intended practice inbox, not a third-party marketing list.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Spot-check the intake/contact form fields"
        },
        {
          "detail": "Check that the form and privacy notice page meet basic WCAG expectations — labeled fields, sufficient color contrast, keyboard navigability.\n\nWhy: Generic functional equivalent check for any accessibility scanner: this protocol names the standard (WCAG 2.x) without assuming a specific tool the practice may not have.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Run a basic accessibility check on the page",
          "why": "Generic functional equivalent check for any accessibility scanner: this protocol names the standard (WCAG 2.x) without assuming a specific tool the practice may not have."
        },
        {
          "detail": "Date, scripts inventoried, any pixels removed/reconfigured, and privacy notice update, kept with the annual compliance record.\n\nRecord: Date, scripts inventoried, any pixels removed/reconfigured, and privacy notice update, kept with the annual compliance record.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the review"
        },
        {
          "detail": "Website privacy and tracking review complete",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Website privacy and tracking review complete"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Website privacy notice, tracking-pixel and form-data review — Analytics, chat or advertising pixels are added to the website, or annually.",
      "title": "Website privacy notice, tracking-pixel and form-data review",
      "trigger": "Analytics, chat or advertising pixels are added to the website, or annually",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200 (calling-hour limits, internal DNC list, National DNC Registry)",
          "source": "TCPA 47 U.S.C. §227 and FCC rules 47 CFR 64.1200 (calling-hour limits, internal DNC list, National DNC Registry)",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        },
        {
          "kind": "regulation",
          "label": "FTC Telemarketing Sales Rule 16 CFR Part 310",
          "source": "FTC Telemarketing Sales Rule 16 CFR Part 310",
          "url": "https://www.ecfr.gov/current/title-16/part-310"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "mkt-017",
      "kind": "compliance",
      "materials": [
        "dormant-patient list export",
        "National Do Not Call Registry lookup access",
        "internal do-not-call/opt-out list",
        "call log template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Export the dormant-patient list from the practice management system for the reactivation window being targeted (e.g. no visit in 18+ months).\n\nWhy: A defined, dated list is what gets scrubbed — a moving target cannot be certified as clean.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Build the candidate call list",
          "why": "A defined, dated list is what gets scrubbed — a moving target cannot be certified as clean."
        },
        {
          "detail": "Cross-check the list against the practice's own do-not-call/opt-out log and remove every match before touching any external registry.\n\nWhy: A patient's own request to the practice controls regardless of registry status.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Remove internal opt-outs first",
          "why": "A patient's own request to the practice controls regardless of registry status."
        },
        {
          "detail": "Run the remaining numbers against the current National DNC Registry and remove matches, keeping the scrub timestamp for the record.\n\nWhy: TCPA/TSR liability attaches per improper call — the scrub has to be current, not a stale cached list.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Scrub against the National Do Not Call Registry",
          "why": "TCPA/TSR liability attaches per improper call — the scrub has to be current, not a stale cached list."
        },
        {
          "detail": "Does an existing patient relationship or prior consent cover this contact?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "covered",
              "label": "Established patient relationship applies (informational recall call, not a robocall/autodialed marketing message)"
            },
            {
              "goto": "s11",
              "id": "uncovered",
              "label": "Cold or lapsed-long-enough that consent basis is unclear"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "marketing",
          "title": "Does an existing patient relationship or prior consent cover this contact?"
        },
        {
          "detail": "Verify the dialing plan restricts calls to 8:00am-9:00pm in the RECIPIENT's local time zone, not the practice's; flag any out-of-window numbers for reschedule.\n\nWhy: Calling-hour limits are keyed to the called party's time zone under federal telemarketing rules.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm calling-hour window per recipient's local time",
          "why": "Calling-hour limits are keyed to the called party's time zone under federal telemarketing rules."
        },
        {
          "detail": "A named compliance officer reviews the scrubbed list size, scrub date, consent-basis split, and hour window, and signs off before any number is dialed.\n\nWhy: Per-call statutory damages make a bad list an expensive mistake — a human checks the batch, not just the software.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before the campaign dials.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before the campaign dials",
          "why": "Per-call statutory damages make a bad list an expensive mistake — a human checks the batch, not just the software."
        },
        {
          "detail": "Dial only the approved list within the approved hours; log connect/no-answer/opt-out/booked for each attempt.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Place calls and log every outcome"
        },
        {
          "detail": "Did the recipient ask to stop being called?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "no-request",
              "label": "No opt-out request"
            },
            {
              "goto": "s12",
              "id": "opt-out",
              "label": "Recipient requested no further calls"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the recipient ask to stop being called?"
        },
        {
          "detail": "Log scrub date, list size before/after scrub, calls placed, opt-outs captured, and appointments booked in the marketing campaign log.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Record campaign results"
        },
        {
          "detail": "Campaign closed and logged",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Campaign closed and logged"
        },
        {
          "detail": "Do not dial; instead route these contacts to a mail or opt-in text invitation that captures express consent before any call is placed.\n\nWhy: TCPA prior-express-consent requirements are strict for autodialed/prerecorded marketing calls — when in doubt, get consent in writing first.",
          "id": "s11",
          "kind": "step",
          "role": "marketing",
          "title": "Move uncertain numbers to a written-consent-first track",
          "why": "TCPA prior-express-consent requirements are strict for autodialed/prerecorded marketing calls — when in doubt, get consent in writing first."
        },
        {
          "detail": "Enter the number into the internal opt-out log the same day, before any further campaign runs.\n\nWhy: An honored opt-out has to persist past this one campaign or the next scrub will miss it.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Add the number to the internal do-not-call list immediately",
          "why": "An honored opt-out has to persist past this one campaign or the next scrub will miss it."
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Outbound reactivation call list do-not-call scrub and calling-hour limits — An outbound reactivation calling campaign is planned.",
      "title": "Outbound reactivation call list do-not-call scrub and calling-hour limits",
      "trigger": "An outbound reactivation calling campaign is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California B&P §650 (referral compensation restrictions)",
          "source": "California B&P §650 (referral compensation restrictions)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=650.&lawCode=BPC"
        },
        {
          "kind": "regulation",
          "label": "FTC Act §5 (truthful, non-deceptive professional communications)",
          "source": "FTC Act §5 (truthful, non-deceptive professional communications)",
          "url": "https://www.ftc.gov/legal-library/browse/statutes/federal-trade-commission-act"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 90,
      "frequency": "quarterly",
      "id": "mkt-018",
      "kind": "compliance",
      "materials": [
        "referral-partner target list",
        "practice introduction packet",
        "referral tracking log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Identify nearby physicians, specialists, and allied providers (orthodontists, oral surgeons, pediatricians, ENTs) who could send or receive referrals with this practice.\n\nWhy: A quarterly cycle without a defined target list drifts into ad hoc outreach that is hard to track.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Build the referral-partner target list",
          "why": "A quarterly cycle without a defined target list drifts into ad hoc outreach that is hard to track."
        },
        {
          "detail": "Is this a new practice opening nearby or an existing relationship renewal?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "new",
              "label": "New nearby practice — introduce the practice fresh"
            },
            {
              "goto": "s9",
              "id": "renewal",
              "label": "Existing relationship — check in and share updates"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this a new practice opening nearby or an existing relationship renewal?"
        },
        {
          "detail": "Assemble a short packet: services offered, hours, how to refer a patient, and a direct contact line — no patient case examples with identifying detail.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Prepare an introduction packet"
        },
        {
          "detail": "Set up an in-person visit, phone call, or brief email introduction with the target contact, dentist-to-dentist where practical.\n\nWhy: Provider-to-provider outreach lands better coming from the treating dentist than from marketing alone.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Schedule the outreach contact",
          "why": "Provider-to-provider outreach lands better coming from the treating dentist than from marketing alone."
        },
        {
          "detail": "Conduct the visit or call, leave the packet or update, and offer a reciprocal-referral relationship.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Deliver the outreach"
        },
        {
          "detail": "Record contact name, specialty, date, outcome, and any follow-up commitment made.",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Log the contact in the referral tracking log"
        },
        {
          "detail": "Schedule a follow-up touchpoint (thank-you note, next quarter's check-in) so the relationship does not go cold.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Set a follow-up reminder"
        },
        {
          "detail": "Outreach cycle logged",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Outreach cycle logged"
        },
        {
          "detail": "Note any new services, scheduling changes, or capacity updates worth sharing with an existing referral partner.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Prepare a check-in update"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Professional referral-partner outreach (physicians, specialists) — The quarterly outreach cycle arrives, or a new physician or specialist opens nearby.",
      "title": "Professional referral-partner outreach (physicians, specialists)",
      "trigger": "The quarterly outreach cycle arrives, or a new physician or specialist opens nearby",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California B&P §1680 (dental advertising restrictions apply to public-facing outreach materials)",
          "source": "California B&P §1680 (dental advertising restrictions apply to public-facing outreach materials)"
        },
        {
          "kind": "regulation",
          "label": "HIPAA marketing authorization 45 CFR 164.508(a)(3) (screening findings are not used for marketing without authorization)",
          "source": "HIPAA marketing authorization 45 CFR 164.508(a)(3) (screening findings are not used for marketing without authorization)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.508"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "mkt-019",
      "kind": "compliance",
      "materials": [
        "event/screening supply kit",
        "parental consent forms (for minors)",
        "screening record forms",
        "practice information handouts"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "dentist",
        "hygienist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm date, location, expected attendance, and whether the event involves screening minors (school health fair) versus a general community booth (health fair, sponsorship table).",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm event details and staffing"
        },
        {
          "detail": "Does this event include hands-on screening of individuals, especially minors?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "screening",
              "label": "Yes — clinical screening of attendees, likely including minors"
            },
            {
              "goto": "s7",
              "id": "no-screening",
              "label": "No — information/sponsorship table only, no hands-on exams"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does this event include hands-on screening of individuals, especially minors?"
        },
        {
          "detail": "Print consent forms for any screening of a minor, to be signed by a parent or guardian before that child is screened.\n\nWhy: A school screening still requires consent for a minor's exam even in an informal setting.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare parental/guardian consent forms",
          "why": "A school screening still requires consent for a minor's exam even in an informal setting."
        },
        {
          "detail": "Assign a dentist or hygienist within scope of practice to perform any hands-on screening; front-desk/marketing staff support with intake and handouts only.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign a licensed clinical staff member to conduct screenings"
        },
        {
          "detail": "Verify a signed parental/guardian consent form is on file for each minor before that child is screened; adults screen themselves via written consent at check-in.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent check before screening each attendee.",
            "type": "safety"
          },
          "id": "s5",
          "kind": "gate",
          "role": "hygienist",
          "title": "Consent check before screening each attendee"
        },
        {
          "detail": "Perform the screening within its stated scope (e.g. visual exam, fluoride varnish where authorized) and note findings on the screening record form.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Conduct the screening"
        },
        {
          "detail": "Distribute practice handouts, hours, and how to schedule — no patient case photos without separate written authorization.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Set up the practice information table"
        },
        {
          "detail": "For attendees who want a follow-up appointment, collect name and contact info directly from them or their parent/guardian — never from the screening record without separate consent.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Collect follow-up contact information from interested attendees"
        },
        {
          "detail": "Log attendance, screenings performed, consent forms collected, and follow-up leads in the marketing event log; store screening records per the practice's clinical record retention policy, not the marketing file.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Record event outcomes"
        },
        {
          "detail": "Event closed and logged",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Event closed and logged"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Community event or school screening participation — An event is scheduled.",
      "title": "Community event or school screening participation",
      "trigger": "An event is scheduled",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Act §5 (channel spend reporting still must not misrepresent results externally)",
          "source": "FTC Act §5 (channel spend reporting still must not misrepresent results externally)",
          "url": "https://www.ftc.gov/legal-library/browse/statutes/federal-trade-commission-act"
        },
        {
          "kind": "generic",
          "label": "No statute or standard governs the internal ROI-review mechanics themselves; the practice functions as a generic small-business marketing-attribution review. — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No statute or standard governs the internal ROI-review mechanics themselves; the practice functions as a generic small-business marketing-attribution review."
          },
          "source": "No statute or standard governs the internal ROI-review mechanics themselves; the practice functions as a generic small-business marketing-attribution review. — Practice policy — no published authority governs this step."
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "mkt-020",
      "kind": "compliance",
      "materials": [
        "new-patient source log",
        "channel spend ledger",
        "monthly ROI report template"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Export the 'how did you hear about us' field for every new patient scheduled or seen in the closed month.\n\nWhy: Attribution is only as good as the intake data collected at the front desk all month.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Pull new-patient source data for the month",
          "why": "Attribution is only as good as the intake data collected at the front desk all month."
        },
        {
          "detail": "Gather actual spend by channel (paid search, social, referral incentives, print, sponsorships) from invoices and ad platform billing.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Pull channel spend for the month"
        },
        {
          "detail": "Match each channel's new-patient count to its spend and calculate cost-per-new-patient for the month.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Reconcile source counts against spend"
        },
        {
          "detail": "Is any channel's cost-per-new-patient a significant outlier this month?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "normal",
              "label": "All channels within normal range"
            },
            {
              "goto": "s9",
              "id": "outlier",
              "label": "One or more channels spiked or collapsed"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "marketing",
          "title": "Is any channel's cost-per-new-patient a significant outlier this month?"
        },
        {
          "detail": "Build the report from the template: new patients by channel, spend by channel, cost-per-patient, and month-over-month trend.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Compile the monthly ROI report"
        },
        {
          "detail": "Walk through the report with the practice owner and office manager; decide whether any channel's budget should shift for next month.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the report with the practice owner"
        },
        {
          "detail": "Log any budget reallocation decided in the review, with the reasoning, in the marketing plan file.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the budget decision"
        },
        {
          "detail": "Monthly ROI review closed",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Monthly ROI review closed"
        },
        {
          "detail": "Check for data-entry errors, a paused campaign, a tracking-link problem, or a genuine market shift before treating the number as real.\n\nWhy: A single bad source-code entry can make an otherwise fine channel look like it failed.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Investigate the outlier before reporting it",
          "why": "A single bad source-code entry can make an otherwise fine channel look like it failed."
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Marketing spend, new-patient source attribution and ROI monthly review — The month closes and new-patient sources are attributed against marketing spend.",
      "title": "Marketing spend, new-patient source attribution and ROI monthly review",
      "trigger": "The month closes and new-patient sources are attributed against marketing spend",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California B&P §650 (prohibition on compensation for patient referrals)",
          "source": "California B&P §650 (prohibition on compensation for patient referrals)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=650.&lawCode=BPC"
        },
        {
          "kind": "statute",
          "label": "Federal Anti-Kickback Statute 42 U.S.C. §1320a-7b (applies where any federal health program payer is in the referral chain)",
          "source": "Federal Anti-Kickback Statute 42 U.S.C. §1320a-7b (applies where any federal health program payer is in the referral chain)",
          "url": "https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 45,
      "frequency": "annual",
      "id": "mkt-021",
      "kind": "compliance",
      "materials": [
        "referring-provider gift list",
        "per-recipient value tracking log",
        "current anti-kickback value-threshold reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "marketing",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "List each referring provider office being considered for a holiday gift, lunch, or token of appreciation, with a proposed item and estimated value.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Build the proposed gift or lunch list"
        },
        {
          "detail": "Add any prior gifts, meals, or sponsorships already given to the same office this calendar year to the proposed new item's value.\n\nWhy: Anti-kickback exposure is based on total annual value to a recipient, not any single gift in isolation.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Check cumulative value already given to each recipient this year",
          "why": "Anti-kickback exposure is based on total annual value to a recipient, not any single gift in isolation."
        },
        {
          "detail": "Does any recipient's cumulative annual value approach or exceed the practice's internal ceiling?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "under",
              "label": "Comfortably under the internal ceiling for every recipient"
            },
            {
              "goto": "s8",
              "id": "over",
              "label": "One or more recipients at or near the ceiling"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does any recipient's cumulative annual value approach or exceed the practice's internal ceiling?"
        },
        {
          "detail": "Compliance officer reviews the final list, per-recipient cumulative values, and item types, and signs off before anything is purchased or delivered.\n\nWhy: Referral-linked gifts are a recurring source of anti-kickback exposure — a named sign-off before spending is cheaper than an investigation after.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before distribution.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before distribution",
          "why": "Referral-linked gifts are a recurring source of anti-kickback exposure — a named sign-off before spending is cheaper than an investigation after."
        },
        {
          "detail": "Purchase only the approved items at the approved values and deliver or send them to each office on the approved list.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Purchase and distribute approved gifts"
        },
        {
          "detail": "Record item, value, and recipient for each gift distributed so next year's cumulative check starts from an accurate baseline.",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Log distributed values against the annual tracking log"
        },
        {
          "detail": "Annual gift cycle closed and logged",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Annual gift cycle closed and logged"
        },
        {
          "detail": "Reduce or remove the proposed item for any recipient over the internal ceiling, or spread it into a lower-value, non-cash form (e.g. a modest food item shared by the whole office).",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Revise the list to bring recipients back under the ceiling"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Gifts to referring providers and physicians: anti-kickback limits — The practice plans holiday gifts or lunches for referring offices.",
      "title": "Gifts to referring providers and physicians: anti-kickback limits",
      "trigger": "The practice plans holiday gifts or lunches for referring offices",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Endorsement Guides 16 CFR Part 255",
          "source": "FTC Endorsement Guides 16 CFR Part 255",
          "url": "https://www.ecfr.gov/current/title-16/part-255"
        },
        {
          "kind": "regulation",
          "label": "FTC Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "source": "FTC Consumer Reviews and Testimonials Rule 16 CFR Part 465",
          "url": "https://www.ecfr.gov/current/title-16/part-465"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mkt-022",
      "kind": "compliance",
      "materials": [
        "creator/patient agreement template",
        "disclosure-language checklist",
        "post preview for approval"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note exactly what is being exchanged — a discount, free treatment, cash payment, or free product — for the post, and who is posting (patient-influencer or paid creator).\n\nWhy: Any material connection between the practice and the poster is what triggers a disclosure duty, regardless of dollar amount.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Identify the material connection",
          "why": "Any material connection between the practice and the poster is what triggers a disclosure duty, regardless of dollar amount."
        },
        {
          "detail": "Does the post include the patient's own treatment photos, video, or before/after content?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "clinical-content",
              "label": "Yes — includes their own clinical case content"
            },
            {
              "goto": "s4",
              "id": "no-clinical-content",
              "label": "No — general practice mention only, no personal clinical content shown"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the post include the patient's own treatment photos, video, or before/after content?"
        },
        {
          "detail": "Before proceeding here, complete the practice's patient photo/testimonial/before-after authorization protocol so the clinical content itself is properly authorized.\n\nWhy: Endorsement disclosure and content authorization are two separate legal duties — clearing one does not clear the other.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Route to the separate patient content authorization protocol first",
          "why": "Endorsement disclosure and content authorization are two separate legal duties — clearing one does not clear the other."
        },
        {
          "detail": "Document the exchange (what is given, what is expected), the required disclosure language, and that the post must be approved before or immediately upon going live.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Prepare a written creator/patient agreement"
        },
        {
          "detail": "Require a plain-language disclosure the average viewer would notice — e.g. clearly stated as sponsored or gifted — placed in the post itself, not buried in a hashtag string or hidden behind a 'more' link.\n\nWhy: FTC guidance requires disclosures to be clear and conspicuous, not just technically present.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Draft clear, unavoidable disclosure language for the post",
          "why": "FTC guidance requires disclosures to be clear and conspicuous, not just technically present."
        },
        {
          "detail": "Compliance officer reviews the actual post text/caption/video for the disclosure's placement and clarity, and for any clinical claims needing dentist review, before the poster is told to publish.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review of the post preview before publication.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review of the post preview before publication"
        },
        {
          "detail": "Does the post make any clinical claim (pain-free, guaranteed results, comparative claims)?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-claims",
              "label": "No clinical claims — experience/appearance only"
            },
            {
              "goto": "s11",
              "id": "has-claims",
              "label": "Yes — contains a clinical or outcome claim"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the post make any clinical claim (pain-free, guaranteed results, comparative claims)?"
        },
        {
          "detail": "Once approved, confirm the post as actually published carries the disclosure exactly as reviewed (screenshots or live-link check).",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Authorize publication and confirm disclosure is live"
        },
        {
          "detail": "File the signed agreement, the approved disclosure text, and a link/screenshot of the live post in the marketing compliance log.",
          "id": "s9",
          "kind": "step",
          "role": "marketing",
          "title": "Log the arrangement and post"
        },
        {
          "detail": "Sponsored/endorsement post closed and logged",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Sponsored/endorsement post closed and logged"
        },
        {
          "detail": "The dentist reviews and edits any clinical or outcome claim in the post before it is authorized, per the practice's marketing content review protocol.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Route clinical claim language to the dentist for review"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Influencer or sponsored post: endorsement disclosure — A patient with a following offers to post about treatment in exchange for a discount, or the practice pays a creator.",
      "title": "Influencer or sponsored post: endorsement disclosure",
      "trigger": "A patient with a following offers to post about treatment in exchange for a discount, or the practice pays a creator",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FTC Act §5 (deceptive promotion practices)",
          "source": "FTC Act §5 (deceptive promotion practices)",
          "url": "https://www.ftc.gov/legal-library/browse/statutes/federal-trade-commission-act"
        },
        {
          "kind": "generic",
          "label": "State-level raffle/lottery and prize-promotion statutes vary and must be checked for the practice's state; no single federal floor covers giveaway mechanics.",
          "source": "State-level raffle/lottery and prize-promotion statutes vary and must be checked for the practice's state; no single federal floor covers giveaway mechanics."
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "mkt-023",
      "kind": "compliance",
      "materials": [
        "official contest rules document",
        "no-purchase-necessary entry method",
        "winner selection log",
        "prize record"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Write down the prize, eligibility, entry method, and proposed timeline for the drawing or contest.",
          "id": "s1",
          "kind": "step",
          "role": "marketing",
          "title": "Define the giveaway concept"
        },
        {
          "detail": "Does entry require any purchase, payment, or patient status (i.e. 'consideration')?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-purchase",
              "label": "Entry is free to anyone — no purchase or payment required"
            },
            {
              "goto": "s12",
              "id": "requires-purchase",
              "label": "Current draft requires a purchase, appointment, or payment to enter"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does entry require any purchase, payment, or patient status (i.e. 'consideration')?"
        },
        {
          "detail": "Write official rules covering eligibility, entry period, entry method(s), odds statement, prize description and value, winner selection method, and how the winner will be notified.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Draft official rules"
        },
        {
          "detail": "Practice owner reviews the official rules, entry mechanics, and prize value, and signs off before the giveaway is announced.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner/compliance sign-off before launch.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner/compliance sign-off before launch"
        },
        {
          "detail": "Post or link the official rules everywhere the giveaway is announced, not just on request.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Publish the official rules alongside the promotion"
        },
        {
          "detail": "Keep entries open for the announced entry period (example: one week) and log entries as they arrive.",
          "id": "s6",
          "kind": "timer",
          "role": "marketing",
          "timer_seconds": 604800,
          "title": "Run the entry period"
        },
        {
          "detail": "Select the winner using the exact method stated in the official rules (e.g. random drawing among all valid entries); log the selection process.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Select the winner per the published method"
        },
        {
          "detail": "Will the winner's name or photo be publicized?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "no-publicity",
              "label": "Winner notified privately only, no public announcement of identity"
            },
            {
              "goto": "s13",
              "id": "publicize",
              "label": "Practice wants to publicize the winner's name/photo"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Will the winner's name or photo be publicized?"
        },
        {
          "detail": "Contact the winner per the notification method stated in the rules and arrange delivery of the prize.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Award the prize and notify the winner"
        },
        {
          "detail": "Log total entries, winner selection method used, prize awarded, and rules publication proof in the marketing compliance log.",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Record the giveaway outcome"
        },
        {
          "detail": "Giveaway closed and logged",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Giveaway closed and logged"
        },
        {
          "detail": "Add an equally easy free entry method (e.g. mail-in or online form) alongside any purchase-linked path, so the promotion is not an unlawful lottery combining prize, chance, and consideration.\n\nWhy: A prize drawing with consideration required and chance-based winner selection can cross into unlawful-lottery territory in many states unless a free entry path exists.",
          "id": "s12",
          "kind": "step",
          "role": "marketing",
          "title": "Add a genuine no-purchase-necessary entry path",
          "why": "A prize drawing with consideration required and chance-based winner selection can cross into unlawful-lottery territory in many states unless a free entry path exists."
        },
        {
          "detail": "Obtain the winner's separate written authorization before publishing their name, photo, or any treatment detail.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent gate before publicizing the winner.",
            "type": "safety"
          },
          "id": "s13",
          "kind": "gate",
          "role": "office-manager",
          "title": "Consent gate before publicizing the winner"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Patient contest, raffle or giveaway compliance — The team proposes a drawing or giveaway to patients or followers.",
      "title": "Patient contest, raffle or giveaway compliance",
      "trigger": "The team proposes a drawing or giveaway to patients or followers",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California B&P §651 (health care advertising restrictions apply if a sponsorship includes any advertising claim about the practice's services)",
          "source": "California B&P §651 (health care advertising restrictions apply if a sponsorship includes any advertising claim about the practice's services)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=651.&lawCode=BPC"
        },
        {
          "kind": "generic",
          "label": "No specific statute governs the routine donate/decline decision itself; this follows generic small-business community-giving practice. — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No specific statute governs the routine donate/decline decision itself; this follows generic small-business community-giving practice."
          },
          "source": "No specific statute governs the routine donate/decline decision itself; this follows generic small-business community-giving practice. — Practice policy — no published authority governs this step."
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mkt-024",
      "kind": "compliance",
      "materials": [
        "donation/sponsorship request intake form",
        "annual community-giving budget",
        "request tracking log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Record who asked, what organization, what is requested (cash, product, sponsorship signage, event presence), and by when.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incoming request"
        },
        {
          "detail": "Check the request amount against what remains in the annual community-giving budget for the year.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Check remaining community-giving budget"
        },
        {
          "detail": "Is the request within the office manager's standing approval threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "within",
              "label": "Within threshold and budget remains"
            },
            {
              "goto": "s8",
              "id": "over-threshold",
              "label": "Above threshold, or budget is tight/exhausted"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the request within the office manager's standing approval threshold?"
        },
        {
          "detail": "Confirm the commitment with the requesting organization, arrange payment/product/sponsorship materials, and set delivery or event date.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Approve and fulfill the request"
        },
        {
          "detail": "Let marketing know about the sponsorship or donation so it can be considered for the content calendar (e.g. a social post about the community event), where appropriate.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Notify marketing of the sponsorship"
        },
        {
          "detail": "Log the request, decision, amount/value if approved, and remaining budget in the request tracking log.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the outcome"
        },
        {
          "detail": "Request closed and logged",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Request closed and logged"
        },
        {
          "detail": "Send the request, budget status, and a recommendation to the practice owner for approve/decline/modify.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Route to the practice owner for a decision"
        },
        {
          "detail": "Owner decision",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "owner-approve",
              "label": "Approve as requested or in modified form"
            },
            {
              "goto": "s10",
              "id": "owner-decline",
              "label": "Decline the request"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Owner decision"
        },
        {
          "detail": "Respond to the requesting organization with a brief, courteous decline, noting budget constraints for the cycle.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Send a polite decline"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Charitable donation and sponsorship request handling — A school, team or nonprofit asks the practice to donate or sponsor.",
      "title": "Charitable donation and sponsorship request handling",
      "trigger": "A school, team or nonprofit asks the practice to donate or sponsor",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "source": "HIPAA marketing authorization 45 CFR 164.508(a)(3)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.508"
        },
        {
          "kind": "statute",
          "label": "California B&P §651 (health care advertising), §1680 (dental advertising)",
          "source": "California B&P §651 (health care advertising), §1680 (dental advertising)"
        },
        {
          "kind": "public_domain",
          "label": "USPS Publication 25 (Business Mail Manual) — mailpiece addressing and design standards for outbound mail",
          "source": "USPS Publication 25 (Business Mail Manual) — mailpiece addressing and design standards for outbound mail",
          "url": "https://pe.usps.com/text/pub25/welcome.htm"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "mkt-025",
      "kind": "compliance",
      "materials": [
        "mail-merge patient list export",
        "postcard or mailer proof",
        "return-address envelope stock",
        "postal permit account"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Export name and mailing address only from the practice management system for the target segment (e.g. six-month recall due, birthday month); do not export clinical fields into the mail-merge file.\n\nWhy: Limiting the export to name and address at the source prevents clinical data from ever reaching a print vendor.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Pull the mail-merge patient list for the campaign segment",
          "why": "Limiting the export to name and address at the source prevents clinical data from ever reaching a print vendor."
        },
        {
          "detail": "Write generic recall or promotional copy (\"It's time for your checkup\") without naming a specific diagnosis, procedure performed, balance owed, or condition on the visible face of the piece.\n\nWhy: A postcard is read by anyone who handles the mail — household members, mail carriers — so any clinical specifics visible on the outside are an unauthorized PHI disclosure.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Draft the postcard or mailer copy",
          "why": "A postcard is read by anyone who handles the mail — household members, mail carriers — so any clinical specifics visible on the outside are an unauthorized PHI disclosure."
        },
        {
          "detail": "Confirm: no diagnosis or procedure name visible; no dollar amount or balance visible; no photo identifiable as a specific patient without separate authorization; envelope (if used) shows no clinical markings; return address is the general practice name only.\n\nRecord: Checklist sign-off recorded with campaign name and reviewer initials in the marketing log",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "PHI minimization checklist before print"
        },
        {
          "detail": "A human reviewer signs off on the proof and the mail-merge list before the file goes to the vendor or printer; sign-off blocks the send until confirmed.\n\nWhy: Direct mail cannot be recalled once printed and mailed, so the human check happens before send, not after.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sign off before the file is released to print.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "office-manager",
          "title": "Sign off before the file is released to print",
          "why": "Direct mail cannot be recalled once printed and mailed, so the human check happens before send, not after."
        },
        {
          "detail": "Route based on who will physically produce and mail the piece.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "third-party",
              "label": "Third-party print/mail vendor"
            },
            {
              "goto": "s7",
              "id": "in-house",
              "label": "Printed and mailed in-house"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "marketing",
          "title": "In-house print or third-party mail vendor?"
        },
        {
          "detail": "Verify the print vendor that will receive the mail-merge list has a signed business associate agreement on file before the list is transmitted, regardless of which fields are included — a list identifying who is a patient of this practice, tied to a mailing address, is itself PHI (patient status plus identity), so the vendor is a business associate whether or not clinical fields are also shared.\n\nWhy: Sharing a patient-identifying list with an outside vendor without a business associate agreement on file is an unauthorized disclosure risk; name-plus-address is not a lesser category that escapes the requirement.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm a business associate agreement or data handling agreement is on file",
          "why": "Sharing a patient-identifying list with an outside vendor without a business associate agreement on file is an unauthorized disclosure risk; name-plus-address is not a lesser category that escapes the requirement."
        },
        {
          "detail": "Transmit the approved mail-merge file and postcard proof to the printer or in-house printer/mail station for production and mailing.",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Release the file for printing and mailing"
        },
        {
          "detail": "Record the campaign name, segment size, mail date, and reviewer sign-off in the marketing campaign log for ROI tracking and future audit.\n\nRecord: Campaign log entry: name, segment count, mail date, reviewer",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Log the campaign"
        },
        {
          "detail": "Hold for roughly two weeks after mailing to allow appointment responses and any returned/undeliverable mail to come back before scoring the campaign.",
          "id": "s9",
          "kind": "timer",
          "role": "marketing",
          "timer_seconds": 1209600,
          "title": "Wait for the response window and returned mail"
        },
        {
          "detail": "Response rate and returned-mail count recorded; segment retired or rolled into the next cycle.",
          "id": "s10",
          "kind": "step",
          "role": "marketing",
          "title": "Campaign complete"
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Physical mail campaigns and postcard PHI minimization — Recall postcards, birthday cards or a mailer are being printed.",
      "title": "Physical mail campaigns and postcard PHI minimization",
      "trigger": "Recall postcards, birthday cards or a mailer are being printed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "U.S. Copyright Act §110 public performance exemptions and general public performance license requirement, 17 U.S.C. §106(4), §110",
          "source": "U.S. Copyright Act §110 public performance exemptions and general public performance license requirement, 17 U.S.C. §106(4), §110",
          "url": "https://www.copyright.gov/title17/92chap1.html#110"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 45,
      "frequency": "annual",
      "id": "mkt-026",
      "kind": "compliance",
      "materials": [
        "current music/video licensing account or subscription",
        "public performance license certificate",
        "streaming service business-use terms",
        "licensing agency demand letter (if any)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "List all sources: waiting-room music player or streaming account, waiting-room television or video, phone hold music, and any music played in operatories where patients can hear it.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify every audio and video source playing in public or patient-facing areas"
        },
        {
          "detail": "A personal or household streaming subscription is generally licensed for private, non-commercial use only; a business-tier or public-performance-licensed subscription is required for a space patients occupy.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "business-licensed",
              "label": "Already on a business/public-performance license"
            },
            {
              "goto": "s7",
              "id": "consumer-only",
              "label": "Running on a personal/consumer account"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is each source licensed for business/public use?"
        },
        {
          "detail": "File the current license certificate or subscription confirmation and note the renewal date in the facility compliance log.\n\nRecord: License certificate/subscription confirmation and renewal date filed in the facility compliance log",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the license coverage and renewal date"
        },
        {
          "detail": "Route based on whether this cycle was triggered by an outside claim of unlicensed use rather than the routine annual review.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-demand",
              "label": "No — routine annual review"
            },
            {
              "goto": "s8",
              "id": "demand-received",
              "label": "Yes — a demand letter or inquiry arrived"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did a licensing agency send a demand letter or inquiry?"
        },
        {
          "detail": "Schedule the next review of music/video licensing coverage for one year from this review, or sooner if a new streaming source or television is added.",
          "id": "s5",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 31536000,
          "title": "Set the next annual review reminder"
        },
        {
          "detail": "All public-facing audio/video sources confirmed licensed for business use and documented; next review scheduled.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Licensing review complete"
        },
        {
          "detail": "Subscribe to a streaming service's business-use tier or a dedicated commercial background-music service that carries public performance licensing, and cancel or restrict the personal account from playing in public areas.\n\nWhy: A personal streaming account's terms of service and the underlying copyright license do not extend performance rights to a commercial waiting room; playing it there is outside the license even though the space is small.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Move to a business-licensed music or video service",
          "why": "A personal streaming account's terms of service and the underlying copyright license do not extend performance rights to a commercial waiting room; playing it there is outside the license even though the space is small."
        },
        {
          "detail": "Forward the demand letter and the current license documentation to the practice owner for review; do not respond to the licensing agency until the owner has reviewed the practice's actual license coverage.\n\nWhy: Confirming what is actually licensed before responding avoids either over-conceding an unfounded claim or under-responding to a valid one.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate the demand letter to the practice owner",
          "why": "Confirming what is actually licensed before responding avoids either over-conceding an unfounded claim or under-responding to a valid one."
        },
        {
          "detail": "The practice owner reviews the license coverage evidence and decides whether to respond confirming coverage, negotiate a licensing agreement, or seek outside counsel, before any reply is sent.\n\nWhy: A licensing demand carries potential financial exposure and is a business decision, not a front-line staff decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner reviews and decides response to the demand.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner reviews and decides response to the demand",
          "why": "A licensing demand carries potential financial exposure and is a business decision, not a front-line staff decision."
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Waiting-room music and video licensing — The practice plays streaming music or video in public areas, or a licensing agency sends a demand.",
      "title": "Waiting-room music and video licensing",
      "trigger": "The practice plays streaming music or video in public areas, or a licensing agency sends a demand",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "U.S. Copyright Office Circular 1 (Copyright Basics) — general copyright ownership/licensing background",
          "source": "U.S. Copyright Office Circular 1 (Copyright Basics) — general copyright ownership/licensing background",
          "url": "https://www.copyright.gov/circs/circ01.pdf"
        },
        {
          "kind": "generic",
          "label": "No single public-domain floor governs the specific use terms of a private stock-photo or font license — those terms are set by the individual license contract each vendor issues, not by a public standard — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single public-domain floor governs the specific use terms of a private stock-photo or font license — those terms are set by the individual license contract each vendor issues, not by a public standard"
          },
          "source": "No single public-domain floor governs the specific use terms of a private stock-photo or font license — those terms are set by the individual license contract each vendor issues, not by a public standard — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "USPTO trademark registration maintenance requirements (Sections 8 and 9 renewal filings), 15 U.S.C. §1058, §1059",
          "source": "USPTO trademark registration maintenance requirements (Sections 8 and 9 renewal filings), 15 U.S.C. §1058, §1059",
          "url": "https://www.uspto.gov/trademarks/maintain"
        },
        {
          "kind": "open_standard",
          "label": "ICANN registrant rights and responsibilities — Registrants' Benefits and Responsibilities",
          "repaired": {
            "action": "replace",
            "evidence": "Registrants' Benefits and Responsibilities - ICANN (page dated 2013-09-16); search results confirm 'the official ICANN page for Registrants' Benefits and Responsibilities was published on September 16, 2013' — no page exists at the previously cited 2013-06-03 URL.",
            "ticket": "PROT-017",
            "was": {
              "source": "ICANN registrant rights and responsibilities — domain renewal and expiration notice standards",
              "url": "https://www.icann.org/resources/pages/benefits-2013-06-03-en"
            }
          },
          "source": "ICANN — Registrants' Benefits and Responsibilities",
          "url": "https://www.icann.org/resources/pages/benefits-2013-09-16-en"
        }
      ],
      "class": "marketing-advertising-compliance",
      "department": "marketing",
      "duration_min": 30,
      "frequency": "quarterly",
      "id": "mkt-027",
      "kind": "compliance",
      "materials": [
        "domain registrar account access",
        "trademark registration certificate (if any)",
        "stock photo and font license receipts",
        "renewal register spreadsheet or tracker"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "marketing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "List every domain name, registered trademark, and licensed creative asset (stock photos, fonts, stock video, icon sets) the practice uses, with the vendor, license terms, and expiry date for each.\n\nWhy: A single register is the only way to see every renewal deadline at once instead of discovering a lapse when the website goes down or a cease-and-desist arrives.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Build or update the asset register",
          "why": "A single register is the only way to see every renewal deadline at once instead of discovering a lapse when the website goes down or a cease-and-desist arrives."
        },
        {
          "detail": "Scan the register for domains, trademarks, or licenses expiring within the next 90 days.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "nothing-due",
              "label": "Nothing due this quarter"
            },
            {
              "goto": "s5",
              "id": "asset-due",
              "label": "One or more assets due for renewal"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is any asset nearing expiry within the next quarter?"
        },
        {
          "detail": "Schedule the next full pass of the asset register for approximately 90 days from now.",
          "id": "s3",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 7776000,
          "title": "Set the next quarterly register review"
        },
        {
          "detail": "All domains, trademarks and licensed assets confirmed current or documented as intentionally lapsed; next review scheduled.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Register review complete"
        },
        {
          "detail": "For each asset nearing expiry, either process the renewal payment through the registrar/licensor/USPTO filing, or make a documented decision not to renew (e.g. an unused domain variant) and note the reason in the register.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Renew or actively let lapse each due asset"
        },
        {
          "detail": "Route based on whether the combined renewal cost is within the standing renewal budget or needs owner approval.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "within-budget",
              "label": "Within the standing renewal budget"
            },
            {
              "goto": "s9",
              "id": "over-budget",
              "label": "Exceeds the standing budget (e.g. new trademark filing)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the renewal exceed the routine renewal budget?"
        },
        {
          "detail": "Record the renewal confirmation number, new expiry date, and amount paid for each asset in the register.\n\nRecord: Renewal confirmation, new expiry date, and amount recorded in the asset register",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm and log each renewal"
        },
        {
          "detail": "Route based on whether an outside party's demand letter (e.g. claiming unlicensed use of a stock photo, font, or a trademark conflict) triggered this review.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-demand",
              "label": "No — routine quarterly review"
            },
            {
              "goto": "s10",
              "id": "demand-received",
              "label": "Yes — a demand letter arrived"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did this cycle start from a copyright or trademark demand letter?"
        },
        {
          "detail": "The practice owner reviews and approves any renewal or new filing (such as a new trademark application) that exceeds the routine renewal budget before payment is submitted.\n\nWhy: A trademark filing or major license purchase is a discretionary spend decision that belongs with the person accountable for the budget.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner approves spend above the routine renewal budget.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner approves spend above the routine renewal budget",
          "why": "A trademark filing or major license purchase is a discretionary spend decision that belongs with the person accountable for the budget."
        },
        {
          "detail": "Forward the demand letter along with the register entry (or lack of one) showing what license coverage exists for the asset in question to the practice owner.\n\nWhy: The owner needs the actual license record, not the marketing team's memory of where an image came from, to evaluate exposure.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate the demand letter to the practice owner with the license evidence",
          "why": "The owner needs the actual license record, not the marketing team's memory of where an image came from, to evaluate exposure."
        },
        {
          "detail": "The practice owner reviews the license evidence and decides whether to respond confirming coverage, remove the disputed asset, negotiate, or involve outside counsel, before any reply is sent to the claimant.\n\nWhy: A copyright or trademark demand carries potential financial and reputational exposure and is a business decision, not a front-line staff decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner reviews and decides response to the demand.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner reviews and decides response to the demand",
          "why": "A copyright or trademark demand carries potential financial and reputational exposure and is a business decision, not a front-line staff decision."
        }
      ],
      "subclass": "marketing-advertising-and-online-presence",
      "summary": "Domain, trademark and licensed-asset (stock photo, font) renewal register — A domain, trademark or asset license nears expiry, or a copyright demand letter arrives.",
      "title": "Domain, trademark and licensed-asset (stock photo, font) renewal register",
      "trigger": "A domain, trademark or asset license nears expiry, or a copyright demand letter arrives",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Labor Code and IWC wage orders — travel time between work sites during the workday is hours worked; DLSE reporting-time pay rules",
          "source": "California Labor Code and IWC wage orders — travel time between work sites during the workday is hours worked; DLSE reporting-time pay rules"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary; 164.308(a)(4) information access management for shared systems across sites",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary; 164.308(a)(4) information access management for shared systems across sites",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for cross-site staffing scheduling and least-privilege access grant/revoke — no vendor system named",
          "source": "Generic functional equivalent for cross-site staffing scheduling and least-privilege access grant/revoke — no vendor system named"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "mlo-001",
      "kind": "operational",
      "materials": [
        "cross-site staffing calendar",
        "credential file (per staff member)",
        "least-privilege access request form",
        "wage-and-hour travel-time log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "compliance-officer",
        "dentist",
        "it-vendor",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager posts the assignment (staff name, receiving site, date/shift) on the cross-site staffing calendar and confirms the staff member has seen it at least 24 hours before the shift.\n\nWhy: Same-day floats without notice are the top driver of missed credential checks.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and confirm the float assignment",
          "why": "Same-day floats without notice are the top driver of missed credential checks."
        },
        {
          "detail": "Confirm current state license or registered-dental-assistant status, CPR/BLS card not expired, and the receiving site's OSHA/bloodborne-pathogen training record is on file for this person.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify credentials valid at the receiving site"
        },
        {
          "detail": "Check whether the receiving site's schedule asks this person to perform anything beyond their default scope (e.g., an assistant asked to place a sealant under a supervising dentist who has not signed off at that site before).",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — scope needs confirmation"
            },
            {
              "advised": false,
              "goto": "s7",
              "id": "no",
              "label": "No — routine duties only"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the day's assignment include a delegated procedure with a scope question?"
        },
        {
          "detail": "Compliance officer checks the delegated-duties chart against the receiving site's supervising dentist and prepares the specific procedure/scope question that dentist must answer before the staff member is scheduled on it.\n\nWhy: Delegated scope is set per supervising dentist, not per staff member — the same assistant can have different allowed duties at two sites.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compliance officer prepares the delegated-duties scope question for the supervising dentist",
          "why": "Delegated scope is set per supervising dentist, not per staff member — the same assistant can have different allowed duties at two sites."
        },
        {
          "detail": "The receiving site's supervising dentist gives an explicit same-day yes/no on whether this staff member is authorized under that dentist's own delegation to perform the procedure in question — a wrong call here is unlicensed or unsupervised practice, not an administrative slip.\n\nWhy: Only the supervising dentist can authorize delegated duties under their own license — an office-manager or compliance-officer confirmation of process is not a substitute for the dentist's own scope decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervising dentist at the receiving site signs off on the delegated scope.",
            "role": "supervising dentist at the receiving site",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Supervising dentist at the receiving site signs off on the delegated scope",
          "why": "Only the supervising dentist can authorize delegated duties under their own license — an office-manager or compliance-officer confirmation of process is not a substitute for the dentist's own scope decision."
        },
        {
          "detail": "Office manager does not release the staff member to the floor at the receiving site until the supervising dentist's licensed_signoff scope confirmation from n4b is recorded.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor confirms scope sign-off is recorded before the shift starts.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor confirms scope sign-off is recorded before the shift starts"
        },
        {
          "detail": "IT vendor (with the office manager as fallback performer at sites with no separate IT vendor) creates a dated, site-scoped login limited to the schedules and charts the person needs for that shift only — not blanket access to the receiving site's full patient database.\n\nWhy: HIPAA minimum-necessary applies within one organization across sites, not just to outside parties.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "IT vendor grants temporary least-privilege system access at the receiving site",
          "why": "HIPAA minimum-necessary applies within one organization across sites, not just to outside parties."
        },
        {
          "detail": "HR records the travel time between the person's home site and the receiving site as hours worked for that day, per state wage-and-hour rules, and confirms mileage or travel-pay policy was applied.\n\nWhy: Travel between work sites during the workday is compensable hours worked, distinct from an ordinary commute.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Log travel time for wage compliance",
          "why": "Travel between work sites during the workday is compensable hours worked, distinct from an ordinary commute."
        },
        {
          "detail": "Receiving-site lead confirms arrival, briefs the person on that day's schedule and any site-specific workflow differences, and confirms the temporary access grant is working before the first patient.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Site lead receives the floated staff member"
        },
        {
          "detail": "Record staff name, dates, receiving site, scope confirmation outcome, access-grant start/end, and travel-time hours in the cross-site staffing log.\n\nRecord: cross-site staffing log entry",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the float assignment"
        },
        {
          "detail": "Office manager or IT vendor revokes the receiving-site access grant at the end of the float period (or the shift, if single-day) and confirms revocation in the access log.\n\nWhy: Access left open after a float is a recurring least-privilege failure found on periodic access reviews.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Revoke temporary access at end of assignment",
          "why": "Access left open after a float is a recurring least-privilege failure found on periodic access reviews."
        },
        {
          "detail": "Float assignment closed",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Float assignment closed"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Team member floating between locations: credentials, scope, travel time and system access — A hygienist, assistant or front-desk member is assigned to a different location for a day or a rotation.",
      "title": "Team member floating between locations: credentials, scope, travel time and system access",
      "trigger": "A hygienist, assistant or front-desk member is assigned to a different location for a day or a rotation",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR §164.502(b) minimum necessary — transfer only the chart information the receiving site's appointment requires",
          "repaired": {
            "action": "replace",
            "evidence": "The minimum necessary standard requires covered entities to evaluate their practices and enhance safeguards as needed to limit unnecessary or inappropriate access to and disclosure of protected health information. ... To comply with §164.502(b), a covered entity must meet specific requirements with respect to a request for, or the use and disclosure of, protected health information.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.502(b) minimum necessary — transfer only the chart information the receiving site's appointment requires",
              "url": "https://www.ecfr.gov/current/title-45/section-164.308"
            }
          },
          "source": "45 CFR §164.502(b)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.502"
        },
        {
          "kind": "generic",
          "label": "For internal cross-site scheduling and chart-transfer note — no vendor system named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for internal cross-site scheduling and chart-transfer note — no vendor system named"
          },
          "source": "For internal cross-site scheduling and chart-transfer note — no vendor system named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "mlo-002",
      "kind": "operational",
      "materials": [
        "shared scheduling system (or per-site calendars)",
        "chart-transfer note template",
        "insurance-participation matrix by site"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "scheduler",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Front desk asks whether the patient is requesting a different site by preference, or is being redirected because their home site is closed or fully booked.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the reason for the cross-site request"
        },
        {
          "detail": "Check the insurance-participation matrix by site — not every location in a group is in-network with the same payers.\n\nWhy: A cross-site booking with a network mismatch produces a surprise bill and a same-day cancellation.",
          "id": "s2",
          "kind": "step",
          "role": "scheduler",
          "title": "Confirm the receiving site accepts the patient's insurance and provider network",
          "why": "A cross-site booking with a network mismatch produces a surprise bill and a same-day cancellation."
        },
        {
          "detail": "Determine whether continuity of care requires the receiving provider to review specific chart notes before the visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "active",
              "label": "Yes — active treatment in progress"
            },
            {
              "advised": false,
              "goto": "s5",
              "id": "routine",
              "label": "No — routine or new-concern visit"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this an active treatment in progress (e.g., mid-restoration, ortho, perio therapy)?"
        },
        {
          "detail": "Front desk or scheduler sends the minimum chart information the receiving provider needs — current treatment plan step, last visit summary, any allergies or medical alerts — through the shared system or a secure internal transfer, not by public channel.\n\nWhy: HIPAA minimum-necessary applies to internal transfers between the same organization's sites just as it does externally.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Send a chart-transfer note to the receiving provider",
          "why": "HIPAA minimum-necessary applies to internal transfers between the same organization's sites just as it does externally."
        },
        {
          "detail": "Scheduler books into the receiving site's calendar, flags it as a cross-site booking, and confirms the patient has directions/parking information for the new location.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Book the appointment at the receiving site"
        },
        {
          "detail": "Receiving-site front desk confirms the chart-transfer note (if any) has been reviewed by the treating provider before the appointment starts.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Receiving site confirms readiness"
        },
        {
          "detail": "Record home site, receiving site, reason for transfer, and whether a chart-transfer note was sent, in the cross-site scheduling log.\n\nRecord: cross-site scheduling log entry",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the cross-site booking"
        },
        {
          "detail": "Cross-site booking complete",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Cross-site booking complete"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Patient transfer or cross-booking between practice locations — A patient wants to be seen at a sister location, or one site is closed and patients are redirected.",
      "title": "Patient transfer or cross-booking between practice locations",
      "trigger": "A patient wants to be seen at a sister location, or one site is closed and patients are redirected",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.12 — separate registration required for each principal place of business where controlled substances are stored or dispensed",
          "source": "DEA 21 CFR 1301.12 — separate registration required for each principal place of business where controlled substances are stored or dispensed",
          "url": "https://www.ecfr.gov/current/title-21/section-1301.12"
        },
        {
          "kind": "statute",
          "label": "California Business & Professions Code §1658 et seq. — Dental Board of California additional-office notification requirements",
          "source": "California Business & Professions Code §1658 et seq. — Dental Board of California additional-office notification requirements",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "statute",
          "label": "California Business & Professions Code §1701.5 — Dental Board of California Fictitious Name Permit (separate from the county/Secretary of State DBA filing)",
          "source": "California Business & Professions Code §1701.5 — Dental Board of California Fictitious Name Permit (separate from the county/Secretary of State DBA filing)",
          "url": "https://www.dbc.ca.gov/licensees/dds/permits/fictitious_name.shtml"
        },
        {
          "kind": "regulation",
          "label": "California Radiation Control Regulations 17 CCR §30108 — x-ray machine registration per location with the CDPH Radiologic Health Branch",
          "source": "California Radiation Control Regulations 17 CCR §30108 — x-ray machine registration per location with the CDPH Radiologic Health Branch",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "public_domain",
          "label": "CMS / NPPES — organizational NPI and payer enrollment per service location",
          "source": "CMS / NPPES — organizational NPI and payer enrollment per service location",
          "url": "https://nppes.cms.hhs.gov/"
        },
        {
          "kind": "statute",
          "label": "CDPH Medical Waste Management Program — generator registration (California Medical Waste Management Act, H&S §117600 et seq.)",
          "repaired": {
            "action": "replace",
            "evidence": "Medical waste generators, whether LQGs or SQGs, located in counties where the state acts as the local enforcement agency, must complete the Generator Registration Application ... Applications should be mailed to: California Department of Public Health, Medical Waste Management Program.",
            "ticket": "PROT-017",
            "was": {
              "source": "California Medical Waste Management Act, H&S §117600 et seq. — generator registration per site",
              "url": "https://calrecycle.ca.gov/MedicalWaste/"
            }
          },
          "source": "CDPH Medical Waste Management Program",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/EMB/MedicalWaste/Generators.aspx"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 180,
      "frequency": "annual",
      "id": "mlo-003",
      "kind": "operational",
      "materials": [
        "per-site registration matrix (spreadsheet or tracker)",
        "DEA registration certificates per location",
        "x-ray machine registration certificates per location",
        "medical-waste generator registration per site",
        "fictitious-name permit / additional-office notification",
        "NPPES organizational NPI and service-location records",
        "payer enrollment files per site"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "office-manager",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Compliance officer opens the tracker listing every location and, per site: DEA registration status/expiry, x-ray machine registration status/expiry, medical-waste generator registration status, fictitious-name/additional-office notification status, and payer enrollment status.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the current per-site registration matrix"
        },
        {
          "detail": "Each principal place of business that stores or dispenses controlled substances must hold its own DEA registration — one registration does not cover a group's second location.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm DEA registration is separate and current per site"
        },
        {
          "detail": "Verify each location's x-ray unit(s) are registered with the state radiologic health authority and inspection/registration renewal is current.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm x-ray machine registration per site"
        },
        {
          "detail": "Each site generating regulated medical waste (sharps, contaminated materials) needs its own generator registration under state medical waste law.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm medical-waste generator registration per site"
        },
        {
          "detail": "Verify two distinct items per site: the county or Secretary of State fictitious business name (DBA) statement for the site's operating name, and the Dental Board of California's separate Fictitious Name Permit under BPC §1701.5; also confirm the dental board's additional-office notification is on file for each location beyond the first.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm fictitious-name permit / additional-office notification per site"
        },
        {
          "detail": "Verify each site is listed as a service location under the group's organizational NPI in NPPES, and that payer enrollment files list the correct service location for claims from that site.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm NPPES service-location and payer enrollment per site"
        },
        {
          "detail": "Compare every line in the matrix against today's date.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "gap",
              "label": "Yes — a gap or near-expiry exists"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "clean",
              "label": "No — all current"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Any registration expired, missing, or expiring within 30 days?"
        },
        {
          "detail": "Compliance officer initiates the renewal or missing-registration filing for each gap, assigns an owner and a due date, and flags any gap that could affect patient care continuity (e.g., a lapsed x-ray registration) to the practice owner immediately.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the renewal or correction for each gap found"
        },
        {
          "detail": "For any lapsed registration that legally blocks an activity at that site (e.g., dispensing a controlled substance without a current DEA registration, or imaging without current x-ray registration), the owner or dentist confirms the activity is paused at that site until the registration is restored.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner or dentist signs off before the site continues the affected activity.",
            "role": "practice-owner or dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner or dentist signs off before the site continues the affected activity"
        },
        {
          "detail": "Record verification date, any gaps found, filings submitted, and resolution date for each line item in the matrix.\n\nRecord: per-site registration matrix, updated with audit date and findings",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the per-site registration matrix"
        },
        {
          "detail": "Registration audit closed for this cycle",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Registration audit closed for this cycle"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Per-site registration matrix: DEA per location, x-ray, waste generator, fictitious name and payer enrollment — A second location opens, or an annual per-site registration audit is due.",
      "title": "Per-site registration matrix: DEA per location, x-ray, waste generator, fictitious name and payer enrollment",
      "trigger": "A second location opens, or an annual per-site registration audit is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1304 (records and inventories) and 21 CFR 1305 (order forms — Form 222 / CSOS for Schedule II transfers between registrants)",
          "source": "DEA 21 CFR 1304 (records and inventories) and 21 CFR 1305 (order forms — Form 222 / CSOS for Schedule II transfers between registrants)",
          "url": "https://www.ecfr.gov/current/title-21/part-1305"
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.12 — each site's controlled-substance stock is tied to that site's own DEA registration; transfer between two registrants must be documented as a distribution, not an informal loan",
          "source": "DEA 21 CFR 1301.12 — each site's controlled-substance stock is tied to that site's own DEA registration; transfer between two registrants must be documented as a distribution, not an informal loan",
          "url": "https://www.ecfr.gov/current/title-21/section-1301.12"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "mlo-004",
      "kind": "operational",
      "materials": [
        "controlled-substance perpetual inventory log per site",
        "DEA order form (Schedule II) or CSOS record",
        "transfer manifest / chain-of-custody note",
        "non-controlled supply transfer log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Office manager or dentist at the requesting site confirms exactly what is short — drug name, schedule, quantity — or which critical supply is out.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the shortage and what is needed"
        },
        {
          "detail": "Route differently — controlled substances have a federal paper trail requirement; ordinary supplies do not.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "controlled",
              "label": "Controlled substance"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "supply",
              "label": "Non-controlled supply"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the item a Schedule II–V controlled substance, or a non-controlled supply?"
        },
        {
          "detail": "A transfer of controlled substances between two locations of the same group is a distribution between two separate DEA registrants, not an internal loan, unless both sites share one registration for that address.\n\nWhy: DEA registration is per principal place of business — moving product between sites without documentation is an unrecorded distribution.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm both sites hold their own current DEA registration",
          "why": "DEA registration is per principal place of business — moving product between sites without documentation is an unrecorded distribution."
        },
        {
          "detail": "For Schedule II, complete a DEA order form (Form 222) or CSOS transaction between the two registrants before the drug physically moves. For Schedule III–V, record the transfer with date, drug, quantity, lot number, and both registrants' signatures in each site's perpetual inventory log.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the required transfer documentation for the schedule involved"
        },
        {
          "detail": "Dentist names who physically carries or couriers the substance between sites per the practice's courier vs staff-carried transfer policy, ensures the transfer manifest / chain-of-custody note travels with the substance at all times, and requires the substance stay in a locked container with a direct hand-off between registrants — no unattended transit.\n\nWhy: A Schedule II-V substance in transit without a named carrier and an accompanying chain-of-custody record is an unrecorded distribution and a diversion-control gap.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Arrange secure physical transfer with chain-of-custody documentation",
          "why": "A Schedule II-V substance in transit without a named carrier and an accompanying chain-of-custody record is an unrecorded distribution and a diversion-control gap."
        },
        {
          "detail": "The dispensing dentist confirms the outgoing quantity against that site's perpetual inventory before release, and the receiving dentist confirms the incoming quantity against the documentation before it is added to the receiving site's stock.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist at each site signs off on the transfer before it is finalized.",
            "role": "dentist at sending site and dentist at receiving site",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist at each site signs off on the transfer before it is finalized"
        },
        {
          "detail": "Sending site records the outgoing quantity and the receiving site records the incoming quantity, each referencing the same transfer documentation.\n\nRecord: perpetual controlled-substance inventory log at both sites",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Update both sites' perpetual inventory logs"
        },
        {
          "detail": "Transfer complete and documented",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Transfer complete and documented"
        },
        {
          "detail": "Office manager records what was transferred, quantity, sending and receiving site, and who carried or shipped it, in the supply transfer log.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the non-controlled supply transfer"
        },
        {
          "detail": "Adjust each site's supply inventory count to reflect the transfer.\n\nRecord: supply inventory log at both sites",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Update inventory counts at both sites"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Controlled-substance and supply transfer between locations — One site is short of a controlled drug or critical supply and another site has stock.",
      "title": "Controlled-substance and supply transfer between locations",
      "trigger": "One site is short of a controlled drug or critical supply and another site has stock",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Business & Professions Code — Dental Board of California additional-office and supervision requirements imply a designated responsible person on site when the owner-dentist is not present",
          "source": "California Business & Professions Code — Dental Board of California additional-office and supervision requirements imply a designated responsible person on site when the owner-dentist is not present",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "For the daily operating roll-up format itself — no vendor system named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for the daily operating roll-up format itself — no vendor system named"
          },
          "source": "For the daily operating roll-up format itself — no vendor system named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 15,
      "frequency": "daily",
      "id": "mlo-005",
      "kind": "operational",
      "materials": [
        "daily site-report template",
        "site-lead designation roster"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Office manager confirms who is acting site lead for that day — the senior clinician or a designated non-clinical lead — and posts it where staff can see it.\n\nWhy: Without a named lead, decisions during the day default to nobody and get delayed until the owner is reachable.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Designate the site lead for the day",
          "why": "Without a named lead, decisions during the day default to nobody and get delayed until the owner is reachable."
        },
        {
          "detail": "Site lead handles routine schedule adjustments, minor staffing gaps, and patient-flow decisions during the day, escalating only what exceeds their authority.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Site lead handles day-of decisions within their authority"
        },
        {
          "detail": "Examples: an incident, a compliance concern, an unplanned closure risk, or a major equipment failure.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "urgent",
              "label": "Yes — notify the owner same day"
            },
            {
              "advised": false,
              "goto": "s5",
              "id": "routine",
              "label": "No — cover it in the daily report"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did anything happen today that needs same-day owner notification?"
        },
        {
          "detail": "Site lead contacts the practice owner directly with what happened, what was done, and what is still open — not held for the end-of-day report.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Site lead notifies the practice owner same day"
        },
        {
          "detail": "Site lead fills the daily report: patient volume, staffing present vs scheduled, any patient complaints, equipment or facility issues, and controlled-substance or safety notes.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete the daily site report"
        },
        {
          "detail": "Send the completed report by end of business day so the owner has a same-day roll-up across every site.\n\nRecord: daily site report",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the daily site report to the owner"
        },
        {
          "detail": "Day closed for this site",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Day closed for this site"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Site lead designation and daily site report to the owner — A location operates without the owner present on a given day.",
      "title": "Site lead designation and daily site report to the owner",
      "trigger": "A location operates without the owner present on a given day",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary — capture only the caller information needed to route and schedule the visit",
          "repaired": {
            "action": "replace",
            "evidence": "45 CFR 164.502(b): a covered entity or business associate must 'make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request,' when using, disclosing, or requesting PHI.",
            "ticket": "PROT-017",
            "was": {
              "source": "HIPAA 45 CFR 164.502(b) minimum necessary — capture only the caller information needed to route and schedule the visit",
              "url": "https://www.ecfr.gov/current/title-45/section-164.308"
            }
          },
          "source": "45 CFR 164.502(b) — Uses and disclosures of protected health information: General rules (minimum necessary standard)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.502"
        },
        {
          "kind": "generic",
          "label": "For centralized call routing and nearest-open-site logic — no vendor system named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for centralized call routing and nearest-open-site logic — no vendor system named"
          },
          "source": "For centralized call routing and nearest-open-site logic — no vendor system named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "mlo-006",
      "kind": "operational",
      "materials": [
        "centralized call queue",
        "site directory with hours and nearest-site map",
        "same-day emergency slot tracker per site"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "scheduler",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Central front-desk staff answers and asks what the caller needs — routine scheduling, a question, or a dental problem today.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Answer the call and ask the reason for calling"
        },
        {
          "detail": "Listen for symptoms that are a medical emergency, not a dental scheduling matter.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "life-threatening",
              "label": "Yes — life-threatening symptoms described"
            },
            {
              "advised": false,
              "goto": "s6",
              "id": "dental-urgent",
              "label": "No — urgent dental problem but not life-threatening"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the caller describe a life-threatening emergency (uncontrolled bleeding, facial swelling affecting breathing/swallowing, trauma with loss of consciousness)?"
        },
        {
          "detail": "Tell the caller: \"This needs emergency medical care right now — please call 911 or go to the nearest emergency room.\" Do not attempt to schedule a dental appointment for a life-threatening presentation. Stay on the line only long enough to confirm they understand.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Advise the caller to call 911 or go to the nearest emergency department now.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "front-desk",
          "title": "Advise the caller to call 911 or go to the nearest emergency department now"
        },
        {
          "detail": "Record caller's stated reason, site routed to, and whether a same-day slot was booked, in the central call log.\n\nRecord: central call routing log entry",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the call routing"
        },
        {
          "detail": "Call handled and routed",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Call handled and routed"
        },
        {
          "detail": "Ask which location the caller normally uses, or use their stated area to identify the nearest site in the group.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the caller's nearest or preferred site"
        },
        {
          "detail": "Check the same-day emergency slot tracker for that site.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "open",
              "label": "Yes — slot available at that site"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "full",
              "label": "No — that site is full today"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "scheduler",
          "title": "Does the caller's preferred/nearest site have a same-day emergency slot open?"
        },
        {
          "detail": "Book the emergency slot and confirm the address and arrival instructions with the caller.",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Book the same-day slot at the caller's site"
        },
        {
          "detail": "Check the same-day emergency slot tracker at neighboring sites and offer the closest one with availability, confirming the caller can get there.",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Offer the next nearest open site with a same-day slot"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Centralized phone queue and emergency-call routing across locations — Calls are answered centrally and a caller must be routed to the right site, including a same-day emergency.",
      "title": "Centralized phone queue and emergency-call routing across locations",
      "trigger": "Calls are answered centrally and a caller must be routed to the right site, including a same-day emergency",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary — use patient contact information only to notify of the closure and reschedule",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary — use patient contact information only to notify of the closure and reschedule",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        },
        {
          "kind": "generic",
          "label": "For closure notification and patient redirection to a sister site — no vendor system named — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for closure notification and patient redirection to a sister site — no vendor system named"
          },
          "source": "For closure notification and patient redirection to a sister site — no vendor system named — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "mlo-007",
      "kind": "operational",
      "materials": [
        "patient reschedule list generator (by site and date range)",
        "closure notice template (phone script, text/email, signage)",
        "sister-site capacity check"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager confirms with the practice owner exactly which site, which dates, and the reason (staffing shortage, utility outage, remodel), and whether patients need notification before their next visit.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the closure reason, dates, and whether it is planned or immediate"
        },
        {
          "detail": "Generate the list of every patient with an appointment at the closed site during the closure window.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the list of affected patients"
        },
        {
          "detail": "Check which nearby sites in the group have open capacity on or near the affected patients' original appointment dates.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Check sister-site capacity for the affected dates"
        },
        {
          "detail": "Weigh distance the patient would need to travel against simply rescheduling at the original site once it reopens.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "redirect",
              "label": "Yes — offer the sister site"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "reschedule-same-site",
              "label": "No — reschedule at the original site once reopened"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a sister site within reasonable distance and has capacity?"
        },
        {
          "detail": "Front desk contacts each patient, explains the closure, and offers the sister site's next available slot, or a later date at the original site if the patient prefers to wait.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact each affected patient with the sister-site option"
        },
        {
          "detail": "Update the closed site's phone greeting, online hours listing, and physical signage so walk-ins and callers are not misdirected during the closure.\n\nWhy: A closure that isn't reflected on the phone tree or listings sends patients to a locked door.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Post closure notice at the site and update phone/online listings",
          "why": "A closure that isn't reflected on the phone tree or listings sends patients to a locked door."
        },
        {
          "detail": "Record closure dates, reason, number of patients affected, and how many were successfully rebooked vs still pending, in the closure log.\n\nRecord: site closure and redirection log",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the closure and redirection outcome"
        },
        {
          "detail": "Closure handled and patients redirected",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Closure handled and patients redirected"
        },
        {
          "detail": "Front desk contacts each patient with the reopening date and reschedules within the original site's calendar once it reopens.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact each affected patient to reschedule at the original site"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Temporary closure of one location with patient redirection — A single site must close for days (staffing, utility, remodel) while others stay open.",
      "title": "Temporary closure of one location with patient redirection",
      "trigger": "A single site must close for days (staffing, utility, remodel) while others stay open",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Business & Professions Code §1658 et seq. (additional-office notification) and §1701.5 (Dental Board Fictitious Name Permit) — fee schedules and advertised names must stay consistent with each site's registered/fictitious name",
          "source": "California Business & Professions Code §1658 et seq. (additional-office notification) and §1701.5 (Dental Board Fictitious Name Permit) — fee schedules and advertised names must stay consistent with each site's registered/fictitious name",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "For a cross-site standardization review — no consultancy system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a cross-site standardization review — no consultancy system reproduced"
          },
          "source": "For a cross-site standardization review — no consultancy system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 90,
      "frequency": "quarterly",
      "id": "mlo-008",
      "kind": "operational",
      "materials": [
        "per-site fee schedule comparison",
        "per-site materials/supplier list",
        "per-site method or protocol variance list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Office manager collects each site's fee schedule for the group's most common procedure codes.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current fee schedule from every site"
        },
        {
          "detail": "Collect each site's list of primary materials and suppliers for common procedures.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current materials and supplier list from every site"
        },
        {
          "detail": "Line up each common procedure code's fee across all sites and flag any that differ beyond a normal local-market range.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Compare fee schedules across sites"
        },
        {
          "detail": "Identify where two sites are using different materials, suppliers, or clinical workflow for the same common procedure.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Compare materials, suppliers and methods across sites"
        },
        {
          "detail": "Some variance is defensible (local market fee differences, a supplier substitution for a supply-chain reason); some is drift that should be corrected.",
          "forks": [
            {
              "advised": false,
              "goto": "s9",
              "id": "exception",
              "label": "Legitimate exception — document and keep"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "standardize",
              "label": "Drift — standardize across sites"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is a found variance a legitimate site-specific exception, or should it be standardized?"
        },
        {
          "detail": "Practice owner and dentist agree the standard, and office manager communicates the change with an effective date to every site lead.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set the standardized fee, material or method and communicate it to all sites"
        },
        {
          "detail": "Record variances found, which were standardized, which were documented as exceptions, and the effective date of any changes.\n\nRecord: cross-site standardization review log",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the quarterly standardization review"
        },
        {
          "detail": "Standardization review closed for this quarter",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Standardization review closed for this quarter"
        },
        {
          "detail": "Record which site, what the variance is, and why it is being kept as an exception rather than standardized.\n\nRecord: standardization review log — documented exception",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Document the exception and its reason"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Cross-site protocol, fee and supply standardization review — Quarterly, or when two sites are found running different methods, fees or materials.",
      "title": "Cross-site protocol, fee and supply standardization review",
      "trigger": "Quarterly, or when two sites are found running different methods, fees or materials",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary; 164.308(a)(4) information access management for shared systems across sites",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary; 164.308(a)(4) information access management for shared systems across sites",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.312(a)(1) access control (unique user identification, automatic logoff) and 164.312(b) audit controls",
          "source": "HIPAA 45 CFR 164.312(a)(1) access control (unique user identification, automatic logoff) and 164.312(b) audit controls",
          "url": "https://www.ecfr.gov/current/title-45/section-164.312"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.308(a)(3) workforce security — authorization/supervision and termination procedures",
          "source": "HIPAA 45 CFR 164.308(a)(3) workforce security — authorization/supervision and termination procedures",
          "url": "https://www.ecfr.gov/current/title-45/section-164.308"
        },
        {
          "kind": "generic",
          "label": "Role-based access matrix design and periodic access review cadence: generic functional equivalent — no vendor system reproduced",
          "source": "Role-based access matrix design and periodic access review cadence: generic functional equivalent — no vendor system reproduced"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "mlo-009",
      "kind": "operational",
      "materials": [
        "practice management system user-admin console",
        "access-request form",
        "role/site access matrix",
        "audit-log export tool",
        "signed confidentiality acknowledgment"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager receives a request (from the staff member's site lead or the staff member) naming the person, the additional site(s) needed, and the business reason (float coverage, cross-site treatment, temporary transfer).\n\nWhy: A documented business reason is what later distinguishes a legitimate multi-site grant from unexplained broad access during an audit.\n\nRecord: access-request form filed with name, sites requested, reason, requestor",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and log the access request",
          "why": "A documented business reason is what later distinguishes a legitimate multi-site grant from unexplained broad access during an audit."
        },
        {
          "detail": "Verify the requesting staff member is currently employed, in good standing, and that their job role (front desk, hygienist, assistant, dentist) is on file before granting anything.\n\nWhy: Access decisions must trace to a real, current employment relationship — this is the first line of workforce security under HIPAA 45 CFR 164.308(a)(3).",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the staff member's current role and employment status",
          "why": "Access decisions must trace to a real, current employment relationship — this is the first line of workforce security under HIPAA 45 CFR 164.308(a)(3)."
        },
        {
          "detail": "Look up what the requested role is normally permitted to see at the requested site (e.g., front desk sees scheduling and demographics; hygienist sees clinical chart and imaging; billing sees ledger) using the practice's documented access matrix.\n\nWhy: Generic functional equivalent — the specific access-control screen varies by system; the practice's own role/site matrix is the actual policy artifact.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Map the request against the role/site access matrix",
          "why": "Generic functional equivalent — the specific access-control screen varies by system; the practice's own role/site matrix is the actual policy artifact."
        },
        {
          "detail": "Compare the requested scope against the documented matrix for that role.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "standard",
              "label": "Yes — standard scope for this role, proceed to grant"
            },
            {
              "advised": false,
              "goto": "s14",
              "id": "broader",
              "label": "No — broader or unusual scope requested, needs compliance review"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the request match the standard role/site matrix?"
        },
        {
          "detail": "Compliance officer signs off that the scope about to be granted is the minimum necessary for the stated role and reason, with an end date set for any temporary access, before IT provisions it.\n\nWhy: This is the checkpoint that turns a request into an authorized grant — provisioning before sign-off would make the audit log show access nobody approved.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off: access is minimum necessary before it is provisioned.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off: access is minimum necessary before it is provisioned",
          "why": "This is the checkpoint that turns a request into an authorized grant — provisioning before sign-off would make the audit log show access nobody approved."
        },
        {
          "detail": "Grant access under the staff member's own unique user account (never a shared or generic login), scoped to the approved site(s) and role permissions, with automatic logoff enabled per the practice's timeout policy.\n\nWhy: HIPAA 45 CFR 164.312(a)(1) requires unique user identification — a shared login makes the audit log meaningless because it cannot show who actually viewed a chart.",
          "id": "s6",
          "kind": "step",
          "role": "it-vendor",
          "title": "Provision the access grant with a unique login",
          "why": "HIPAA 45 CFR 164.312(a)(1) requires unique user identification — a shared login makes the audit log meaningless because it cannot show who actually viewed a chart."
        },
        {
          "detail": "Staff member signs a confidentiality acknowledgment confirming they understand the scope of access granted and that viewing records outside that scope or their job duty is a policy violation.\n\nWhy: A signed acknowledgment gives the practice a documented basis for corrective action if the access is later misused.\n\nRecord: signed confidentiality acknowledgment filed with the access-request form",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect the confidentiality acknowledgment",
          "why": "A signed acknowledgment gives the practice a documented basis for corrective action if the access is later misused."
        },
        {
          "detail": "Office manager confirms to the staff member that access is live and tells the receiving site's lead who now has access and for how long, so the site is aware.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the staff member and the receiving site lead that access is active"
        },
        {
          "detail": "This check is independent of the scheduled end date or the periodic review cadence — a termination event revokes access immediately, whenever it is reported, rather than waiting for either.\n\nWhy: HIPAA 45 CFR 164.308(a)(3) workforce security requires termination procedures; a terminated staff member's access must not ride out a temporary grant's end date or wait for the next quarterly review.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "active",
              "label": "No — still employed, continue with the normal access lifecycle"
            },
            {
              "advised": false,
              "goto": "s15",
              "id": "terminated",
              "label": "Yes — terminated, revoke immediately"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Has HR reported this staff member terminated since the grant was requested or at any later point in this access's life?",
          "why": "HIPAA 45 CFR 164.308(a)(3) workforce security requires termination procedures; a terminated staff member's access must not ride out a temporary grant's end date or wait for the next quarterly review."
        },
        {
          "detail": "Confirm whether the access was approved as time-limited (a rotation, a coverage day) or as an ongoing part of the staff member's role.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "temporary",
              "label": "Temporary — schedule automatic revocation on the end date"
            },
            {
              "advised": false,
              "goto": "s16",
              "id": "ongoing",
              "label": "Ongoing — add to the standing periodic review list"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a temporary or ongoing grant?"
        },
        {
          "detail": "Access remains active only through the end date set at approval; IT (or the scheduled access-control job) revokes it automatically on that date without waiting for a new request. (duration_min is recorded as 0 because the wait length is not fixed — it depends on the case's approved end date, not a static number of minutes; a termination event, if any, is handled separately at termination_check and does not wait for this timer.)\n\nWhy: Temporary access that is never revoked is how orphaned accounts accumulate — the leading finding in access-matrix audits.\n\nCadence: 0 minute(s) (no valid timer duration in source — downgraded from a timer step).",
          "id": "s11",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hold access until the approved end date, then revoke",
          "why": "Temporary access that is never revoked is how orphaned accounts accumulate — the leading finding in access-matrix audits."
        },
        {
          "detail": "Record the revocation date and confirm in the audit log that the account no longer shows access to the other site's records.\n\nRecord: revocation date and audit-log confirmation filed with the access-request form",
          "id": "s12",
          "kind": "step",
          "role": "it-vendor",
          "title": "Log the revocation"
        },
        {
          "detail": "Access request closed and documented",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Access request closed and documented"
        },
        {
          "detail": "Compliance officer evaluates whether the expanded scope is justified by the stated business reason (e.g., a site-lead covering two locations, a temporary cross-site rotation) and whether a narrower alternative would work instead.\n\nWhy: Minimum necessary (45 CFR 164.502(b)) applies to every grant, not only the routine ones — an unusual request is exactly where over-provisioning tends to happen.",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review the broader-than-standard request",
          "why": "Minimum necessary (45 CFR 164.502(b)) applies to every grant, not only the routine ones — an unusual request is exactly where over-provisioning tends to happen."
        },
        {
          "detail": "IT revokes the multi-site access grant the same day termination is confirmed by HR — do not wait for the scheduled end date, the next periodic review, or a new request.\n\nWhy: Access left active after a termination is the exact HIPAA workforce-security gap 45 CFR 164.308(a)(3) exists to close.",
          "id": "s15",
          "kind": "step",
          "role": "it-vendor",
          "title": "Revoke the access grant immediately on confirmed termination",
          "why": "Access left active after a termination is the exact HIPAA workforce-security gap 45 CFR 164.308(a)(3) exists to close."
        },
        {
          "detail": "List the staff member, role, site(s), and grant date on the practice's periodic (at minimum quarterly) access review so ongoing multi-site access is re-confirmed as still needed, not assumed indefinitely.",
          "id": "s16",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Add the ongoing grant to the periodic access-matrix review"
        },
        {
          "detail": "Ongoing multi-site grants sit on the standing list until the next quarterly access review runs.\n\nWhy: A fixed review cadence is what catches access that outlived its business reason — a departed rotation, a role that changed — before it becomes a stale account.",
          "id": "s17",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 7776000,
          "title": "Wait for the scheduled periodic review",
          "why": "A fixed review cadence is what catches access that outlived its business reason — a departed rotation, a role that changed — before it becomes a stale account."
        },
        {
          "detail": "Compliance officer confirms with the site lead whether the staff member still needs access to the other site's records.",
          "forks": [
            {
              "advised": true,
              "goto": "s19",
              "id": "still-needed",
              "label": "Yes — still needed, keep active and re-date the next review"
            },
            {
              "advised": false,
              "goto": "s19",
              "id": "no-longer-needed",
              "label": "No — revoke access now"
            }
          ],
          "id": "s18",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the ongoing access still justified at review?"
        },
        {
          "detail": "Record the review date, decision, and (if revoked) the revocation confirmation in the access-matrix review log.\n\nRecord: review date, decision and outcome filed in the access-matrix review log",
          "id": "s19",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the review outcome"
        }
      ],
      "subclass": "multi-location-and-group-practice-operations",
      "summary": "Shared patient database across locations: role-based access by site — Locations share one practice database and a staff member needs access to another site's patients.",
      "title": "Shared patient database across locations: role-based access by site",
      "trigger": "Locations share one practice database and a staff member needs access to another site's patients",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; front-desk opening never itself handles the controlled-substance safe (that is the end-of-day walkthrough's job, oc-009) — cited here only to establish the class rests on documented regulatory practice, not as a claim this routine performs that check.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; front-desk opening never itself handles the controlled-substance safe (that is the end-of-day walkthrough's job, oc-009) — cited here only to establish the class rests on documented regulatory practice, not as a claim this routine performs that check.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For opening checklists: time-boxed sequence, security-then-communications-then-money-then-schedule order; no vendor front-office system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for opening checklists: time-boxed sequence, security-then-communications-then-money-then-schedule order; no vendor front-office system reproduced"
          },
          "source": "For opening checklists: time-boxed sequence, security-then-communications-then-money-then-schedule order; no vendor front-office system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "daily",
      "id": "oc-001",
      "kind": "operational",
      "materials": [
        "door and alarm keys/codes",
        "cash drawer starting bank",
        "day schedule printout",
        "voicemail and portal access",
        "sign-in sheet or check-in tablet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Unlock the front and any staff entrance, disarm the alarm system with the code, and turn on reception-area lights.\n\nWhy: Security first — an alarm left armed traps the next arrival outside, and a door left unlocked overnight is a facility incident to catch immediately, not after the phones start ringing.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Unlock doors and disarm security system",
          "why": "Security first — an alarm left armed traps the next arrival outside, and a door left unlocked overnight is a facility incident to catch immediately, not after the phones start ringing."
        },
        {
          "detail": "Walk the reception area and hallway: no signs of break-in, water leak, or equipment left on overnight; report anything abnormal to the office manager before continuing.\n\nWhy: A five-second visual check catches an overnight problem while there is still time to fix it before patients arrive.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Quick walkthrough for anything out of place",
          "why": "A five-second visual check catches an overnight problem while there is still time to fix it before patients arrive."
        },
        {
          "detail": "Switch the phone system out of the after-hours greeting and confirm the ring group routes to the front desk.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Take phones off night mode"
        },
        {
          "detail": "Review every overnight voicemail and patient-portal message; flag anything urgent (pain, swelling, bleeding) for immediate callback and route billing/insurance messages to the appropriate role.\n\nWhy: An overnight message from a patient in pain needs a callback before the schedule fills, not at the end of the shift.\n\nRecord: message log with disposition per item",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Triage voicemail and portal messages",
          "why": "An overnight message from a patient in pain needs a callback before the schedule fills, not at the end of the shift."
        },
        {
          "detail": "Count the drawer against the expected opening bank and log the total.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Count the starting cash drawer"
        },
        {
          "detail": "A second person (office manager or designated staff) independently confirms the counted total before the day begins; any variance is logged and escalated per the cash-drawer protocol.\n\nWhy: Two-person verification at open protects both the practice and the front-desk staff member from a disputed shortage.\n\nRecord: opening cash count with two initials",
          "gate": {
            "ack": "I confirm I have completed this step as written: Second-person verification of drawer count.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Second-person verification of drawer count",
          "why": "Two-person verification at open protects both the practice and the front-desk staff member from a disputed shortage."
        },
        {
          "detail": "Print the day's schedule (or open the digital view), note new patients, medical-alert flags, and lab-case-due appointments, and route copies to hygiene and clinical bays.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Print and route the day schedule"
        },
        {
          "detail": "Confirm reception is staffed, phones are live, and the schedule is distributed before the daily huddle begins.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off readiness to the morning huddle"
        },
        {
          "detail": "Opening routine complete",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Opening routine complete"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Front desk opening routine — Front desk arrives 30 minutes before the first patient: unlock, disarm, phones off night mode, voicemail and portal messages triaged, cash drawer counted, day schedule printed and routed.",
      "title": "Front desk opening routine",
      "trigger": "Front desk arrives 30 minutes before the first patient: unlock, disarm, phones off night mode, voicemail and portal messages triaged, cash drawer counted, day schedule printed and routed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — waterline flushing, sterilizer daily checks at open/close",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — waterline flushing, sterilizer daily checks at open/close",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 20,
      "frequency": "daily",
      "id": "oc-002",
      "kind": "operational",
      "materials": [
        "compressor and vacuum system",
        "dental unit waterline flush access",
        "sterilizer with daily mechanical/chemical/biological indicator supplies",
        "operatory stock par lists"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Turn on the central compressor and vacuum system and confirm normal pressure gauges before use.\n\nWhy: Handpieces and suction cannot run without these systems up and stable; catching a pressure fault now avoids a mid-procedure failure.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Power on compressor and vacuum",
          "why": "Handpieces and suction cannot run without these systems up and stable; catching a pressure fault now avoids a mid-procedure failure."
        },
        {
          "detail": "Flush each dental unit waterline and handpiece line for two minutes into a sink or basin before first patient use.\n\nWhy: Waterlines left standing overnight can grow biofilm; a documented flush is the CDC-cited daily control.\n\nRecord: waterline flush log entry per operatory",
          "id": "s2",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 120,
          "title": "Flush dental unit waterlines",
          "why": "Waterlines left standing overnight can grow biofilm; a documented flush is the CDC-cited daily control."
        },
        {
          "detail": "Power on the sterilizer and allow it to reach operating cycle readiness before the day's first load.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Warm up sterilizer"
        },
        {
          "detail": "Verify the sterilizer's mechanical gauges/printout, run and confirm a chemical indicator, and log the result before processing instruments for the day.\n\nWhy: A sterilizer that failed overnight must be caught before any instrument set is processed and used on a patient.\n\nRecord: daily sterilizer log",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Sterilizer daily mechanical and chemical check",
          "why": "A sterilizer that failed overnight must be caught before any instrument set is processed and used on a patient."
        },
        {
          "detail": "Did the sterilizer pass its daily check?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "pass",
              "label": "Passed — proceed"
            },
            {
              "goto": "s9",
              "id": "fail",
              "label": "Failed — hold sterilization"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Did the sterilizer pass its daily check?"
        },
        {
          "detail": "Set up each operatory with the supplies needed for that day's scheduled procedure types, referencing the par-level stock list.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Stock operatories per the day's schedule"
        },
        {
          "detail": "Report clinical-side readiness (equipment on, waterlines flushed, sterilizer passed, operatories stocked) at the daily huddle.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm clinical readiness to the huddle"
        },
        {
          "detail": "Clinical opening routine complete",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Clinical opening routine complete"
        },
        {
          "detail": "Take the sterilizer out of service, notify the office manager and dentist, and switch to a backup sterilizer or reschedule procedures requiring sterile instruments until resolved.\n\nWhy: Processing instruments through a failed sterilizer is a direct infection-control risk to every patient seen that day.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate sterilizer failure before processing continues.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "office-manager",
          "title": "Escalate sterilizer failure before processing continues",
          "why": "Processing instruments through a failed sterilizer is a direct infection-control risk to every patient seen that day."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Clinical opening routine (compressor, vacuum, waterlines, sterilizer warm-up) — The first clinical team member arrives: compressor and vacuum on, waterlines flushed two minutes, sterilizer warm-up and daily mechanical/chemical check, operatories stocked.",
      "title": "Clinical opening routine (compressor, vacuum, waterlines, sterilizer warm-up)",
      "trigger": "The first clinical team member arrives: compressor and vacuum on, waterlines flushed two minutes, sterilizer warm-up and daily mechanical/chemical check, operatories stocked",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "— daily emergency equipment readiness check, no single OSHA provision confirmed to require it — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic functional equivalent — daily emergency equipment readiness check, no single OSHA provision confirmed to require it"
          },
          "repaired": {
            "action": "generic",
            "evidence": "29 CFR 1910.38 (Emergency Action Plans) governs written fire/evacuation planning — reporting an emergency, evacuation procedures, accounting for evacuated employees, and rescue/medical duties — with no element addressing equipment functionality. 29 CFR 1910.151 (Medical Services and First Aid) likewise addresses only physician availability, first-aid supplies/training, and eye/body flushing for corrosive exposure — no daily readiness-check requirement for equipment like oxygen or an AED.",
            "ticket": "PROT-017",
            "was": {
              "source": "OSHA 29 CFR 1910.38 Emergency Action Plans — readiness of emergency equipment",
              "url": "https://www.ecfr.gov/current/title-29/section-1910.38"
            }
          },
          "source": "— daily emergency equipment readiness check, no single OSHA provision confirmed to require it — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "For a daily emergency-kit readiness check: pressure/indicator/expiration/seal verification logged daily; no vendor kit reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a daily emergency-kit readiness check: pressure/indicator/expiration/seal verification logged daily; no vendor kit reproduced"
          },
          "source": "For a daily emergency-kit readiness check: pressure/indicator/expiration/seal verification logged daily; no vendor kit reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 10,
      "frequency": "daily",
      "id": "oc-003",
      "kind": "operational",
      "materials": [
        "portable oxygen tank with regulator",
        "AED",
        "sealed emergency drug kit",
        "daily equipment check log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the portable oxygen tank's pressure gauge is in the acceptable range and the regulator and mask are attached and functional.\n\nWhy: Oxygen delivery is the first response to most medical emergencies in the dental chair; a low or empty tank found mid-emergency is too late.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Verify oxygen tank pressure",
          "why": "Oxygen delivery is the first response to most medical emergencies in the dental chair; a low or empty tank found mid-emergency is too late."
        },
        {
          "detail": "Confirm the AED's status indicator shows green/ready and the pad expiration date has not passed.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Verify AED readiness indicator"
        },
        {
          "detail": "Confirm the emergency drug kit's tamper seal is intact, then read the earliest expiration date off the kit's externally visible expiration label (the date the practice affixes to the outside of a sealed kit); do not open the kit to check individual items unless the seal is already broken.\n\nWhy: An intact seal is the fastest proof the kit has not been used or picked over; breaking it to inspect would itself compromise readiness.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Verify emergency drug kit seal and expiration",
          "why": "An intact seal is the fastest proof the kit has not been used or picked over; breaking it to inspect would itself compromise readiness."
        },
        {
          "detail": "Did everything pass?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "pass",
              "label": "All items pass — log and proceed"
            },
            {
              "goto": "s7",
              "id": "fail",
              "label": "Something failed or expired"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Did everything pass?"
        },
        {
          "detail": "Initial and date the daily emergency equipment check log, noting any items replaced.\n\nRecord: daily emergency equipment readiness log",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Initial the daily equipment log"
        },
        {
          "detail": "Emergency equipment check complete",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Emergency equipment check complete"
        },
        {
          "detail": "Notify the dentist immediately and remove/replace the failed item (refill oxygen, replace AED pads, reorder expired kit contents) before the first patient is seen.\n\nWhy: The practice cannot safely treat patients that day without functioning emergency response equipment on hand.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate a failed or expired emergency item to the dentist.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Escalate a failed or expired emergency item to the dentist",
          "why": "The practice cannot safely treat patients that day without functioning emergency response equipment on hand."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Daily emergency equipment readiness check (oxygen, AED, drug kit) — Start of every clinical day: oxygen tank pressure verified, AED indicator green, emergency kit sealed and in date, log initialed.",
      "title": "Daily emergency equipment readiness check (oxygen, AED, drug kit)",
      "trigger": "Start of every clinical day: oxygen tank pressure verified, AED indicator green, emergency kit sealed and in date, log initialed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security — the same dual-custody logic this class's public floor applies to controlled-substance security is generalized here to cash-handling internal controls",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security — the same dual-custody logic this class's public floor applies to controlled-substance security is generalized here to cash-handling internal controls",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For cash-handling internal controls: dual count, independent verification, discrepancy escalation; no vendor cash-management system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for cash-handling internal controls: dual count, independent verification, discrepancy escalation; no vendor cash-management system reproduced"
          },
          "source": "For cash-handling internal controls: dual count, independent verification, discrepancy escalation; no vendor cash-management system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 10,
      "frequency": "daily",
      "id": "oc-004",
      "kind": "operational",
      "materials": [
        "cash drawer",
        "denomination count sheet",
        "safe or lockbox for deposit prep"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Count the drawer by denomination against the expected opening bank (or the day's collected total at close) and record the total on the count sheet.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "First-person cash count"
        },
        {
          "detail": "A second person independently recounts the drawer without seeing the first count's written total, then compares results.\n\nWhy: An independent second count, done blind to the first total, is what actually catches an error or shortage rather than just re-confirming the same number.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Second-person independent verification.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "office-manager",
          "title": "Second-person independent verification",
          "why": "An independent second count, done blind to the first total, is what actually catches an error or shortage rather than just re-confirming the same number."
        },
        {
          "detail": "Do the two counts match?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "match",
              "label": "Counts match"
            },
            {
              "goto": "s6",
              "id": "mismatch",
              "label": "Counts do not match"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Do the two counts match?"
        },
        {
          "detail": "Record the final verified total on the count sheet with both people's initials and the date/time.\n\nRecord: cash drawer count log, open and close, both initials",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the count with both initials"
        },
        {
          "detail": "Cash drawer count complete",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Cash drawer count complete"
        },
        {
          "detail": "Both people recount the drawer together, item by item, to isolate where the discrepancy originates.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Recount together"
        },
        {
          "detail": "Resolved on recount?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "resolved",
              "label": "Resolved — matches now"
            },
            {
              "goto": "s8",
              "id": "unresolved",
              "label": "Still does not match"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Resolved on recount?"
        },
        {
          "detail": "Document the exact discrepancy amount and circumstances and notify the practice owner before the drawer is used further that day.\n\nWhy: An unexplained cash shortage or overage is a financial-controls issue that needs owner visibility, not silent write-off by front-desk staff.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate unresolved discrepancy to the owner.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Escalate unresolved discrepancy to the owner",
          "why": "An unexplained cash shortage or overage is a financial-controls issue that needs owner visibility, not silent write-off by front-desk staff."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Cash drawer open and close count with two-person verification — Opening and closing of any day cash is handled: count, log, second initial, discrepancy escalation.",
      "title": "Cash drawer open and close count with two-person verification",
      "trigger": "Opening and closing of any day cash is handled: count, log, second initial, discrepancy escalation",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plans",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.38"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterile stock and waterline continuity during utility disruption",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterile stock and waterline continuity during utility disruption",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "oc-005",
      "kind": "operational",
      "materials": [
        "utility provider outage-report line",
        "IT vendor contact",
        "paper/offline copy of the day schedule",
        "patient contact list for rescheduling calls",
        "cooler/ice for refrigerated drugs if outage is extended"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk",
        "assistant",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Determine whether power, water pressure, or internet (or a combination) is out, and check whether it is building-wide, block-wide, or isolated to the office.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify what is out and how widespread"
        },
        {
          "detail": "Keep sterilizer and autoclave doors closed to preserve sterility if a cycle was mid-run; move refrigerated medications to a cooler with ice if the outage may extend past a couple of hours.\n\nWhy: A power loss mid-sterilization cycle can compromise sterility, and refrigerated drugs have a defined temperature excursion window before they must be discarded.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Protect sterile stock and refrigerated drugs",
          "why": "A power loss mid-sterilization cycle can compromise sterility, and refrigerated drugs have a defined temperature excursion window before they must be discarded."
        },
        {
          "detail": "Can the day proceed safely, in whole or in part?",
          "forks": [
            {
              "goto": "s10",
              "id": "full-close",
              "label": "Cannot operate — close the day"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "partial",
              "label": "Some procedures can proceed once the scope check above confirms which ones do not depend on what is out (e.g. water out but power/exam still possible)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Can the day proceed safely, in whole or in part?"
        },
        {
          "detail": "Compare today's schedule against exactly which utility is out (from the earlier scope check) and split appointments into those that need the affected utility and those that do not.\n\nWhy: Only appointments that actually depend on the missing utility need to be touched; folding every scheduled patient into a full reschedule during a partial outage undoes the point of staying partially open.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify which scheduled procedures actually require the affected utility",
          "why": "Only appointments that actually depend on the missing utility need to be touched; folding every scheduled patient into a full reschedule during a partial outage undoes the point of staying partially open."
        },
        {
          "detail": "Call or message only the patients whose scheduled procedure needs the affected utility, explain the outage briefly, and offer the next available slot; patients whose appointments do not depend on the missing utility proceed on the existing schedule.\n\nWhy: Reaching only the patients who actually cannot be seen protects the rest of the day's schedule instead of clearing it unnecessarily.\n\nRecord: reschedule call log per affected patient",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify and reschedule only the affected patients",
          "why": "Reaching only the patients who actually cannot be seen protects the rest of the day's schedule instead of clearing it unnecessarily."
        },
        {
          "detail": "Call the utility provider's outage line or the IT vendor to report the issue and get an estimated restoration time.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Report the outage to the utility or IT vendor"
        },
        {
          "detail": "Is this likely to extend past the day?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "short",
              "label": "Expected to resolve same day"
            },
            {
              "goto": "s11",
              "id": "extended",
              "label": "Expected to extend beyond the day"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this likely to extend past the day?"
        },
        {
          "detail": "Check periodically for restoration; once power/water/internet is confirmed stable, resume normal opening steps (compressor, waterline flush, sterilizer check) before seeing patients.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Monitor for restoration and reopen"
        },
        {
          "detail": "Outage response complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Outage response complete"
        },
        {
          "detail": "Call or message every affected patient before they leave for their appointment, explain the outage briefly, and offer the next available slot.\n\nWhy: Reaching patients before they travel to a closed office protects the patient relationship and avoids a wasted trip.\n\nRecord: reschedule call log per patient",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify affected patients and reschedule",
          "why": "Reaching patients before they travel to a closed office protects the patient relationship and avoids a wasted trip."
        },
        {
          "detail": "Notify the practice owner and initiate the multi-day shutdown protocol if the outage is expected to last more than one day.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate an extended outage to the practice owner.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Escalate an extended outage to the practice owner"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Opening when power, water or internet is out — The opener finds no power, no water pressure or no internet at open — decide see/reschedule, notify patients, protect sterile stock and refrigerated drugs.",
      "title": "Opening when power, water or internet is out",
      "trigger": "The opener finds no power, no water pressure or no internet at open — decide see/reschedule, notify patients, protect sterile stock and refrigerated drugs",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plans — named-role escalation ladder for a disruption to normal operations",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plans — named-role escalation ladder for a disruption to normal operations",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.38"
        },
        {
          "kind": "generic",
          "label": "For a staffing-gap escalation ladder: attempt contact, apply a time threshold, notify affected patients, escalate to ownership; no vendor scheduling system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a staffing-gap escalation ladder: attempt contact, apply a time threshold, notify affected patients, escalate to ownership; no vendor scheduling system reproduced"
          },
          "source": "For a staffing-gap escalation ladder: attempt contact, apply a time threshold, notify affected patients, escalate to ownership; no vendor scheduling system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "oc-006",
      "kind": "operational",
      "materials": [
        "provider emergency contact list",
        "on-call/backup provider list if any",
        "day schedule with contact info per patient"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Call and text the provider's personal and emergency contact numbers; check for any known reason (traffic, personal emergency) via other staff who may know.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Attempt to contact the provider"
        },
        {
          "detail": "Was contact made?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "reached",
              "label": "Reached — provider gives an ETA or reason"
            },
            {
              "goto": "s7",
              "id": "unreached",
              "label": "Cannot reach the provider"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was contact made?"
        },
        {
          "detail": "Is the ETA short enough to hold the first patient(s)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "short-delay",
              "label": "Short delay — hold and inform waiting patients"
            },
            {
              "goto": "s8",
              "id": "long-delay",
              "label": "Long delay — reschedule affected appointments"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the ETA short enough to hold the first patient(s)?"
        },
        {
          "detail": "Tell patients as they check in that the provider is running a few minutes behind and give a realistic new time.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Inform arriving/waiting patients of the short delay"
        },
        {
          "detail": "Document what happened, who was contacted, and the resolution for HR follow-up if needed.\n\nRecord: staffing-gap incident log",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the staffing-gap incident"
        },
        {
          "detail": "Staffing-gap response complete",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Staffing-gap response complete"
        },
        {
          "detail": "The office manager decides whether to activate a backup/on-call provider, delay the day, or begin rescheduling, and notifies the practice owner.\n\nWhy: A key clinical provider who cannot be reached is a decision only office leadership should make, not front desk acting alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate an unreachable provider to the office manager.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "office-manager",
          "title": "Escalate an unreachable provider to the office manager",
          "why": "A key clinical provider who cannot be reached is a decision only office leadership should make, not front desk acting alone."
        },
        {
          "detail": "Call each affected patient before they arrive, explain briefly, and offer the next available appointment or a same-day slot with a covering provider if available.\n\nRecord: reschedule call log per patient",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Notify and reschedule affected patients"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Provider or key staff late or absent at opening — A dentist or hygienist has not arrived 15 minutes before the first patient and cannot be reached.",
      "title": "Provider or key staff late or absent at opening",
      "trigger": "A dentist or hygienist has not arrived 15 minutes before the first patient and cannot be reached",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; front-desk closing never itself handles the controlled-substance safe (that is the end-of-day walkthrough's job, oc-009) — cited here only to establish the class rests on documented regulatory practice, not as a claim this routine performs that check.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; front-desk closing never itself handles the controlled-substance safe (that is the end-of-day walkthrough's job, oc-009) — cited here only to establish the class rests on documented regulatory practice, not as a claim this routine performs that check.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For closing checklists: balance-then-prep-then-tomorrow-then-security order; no vendor front-office system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for closing checklists: balance-then-prep-then-tomorrow-then-security order; no vendor front-office system reproduced"
          },
          "source": "For closing checklists: balance-then-prep-then-tomorrow-then-security order; no vendor front-office system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "daily",
      "id": "oc-007",
      "kind": "operational",
      "materials": [
        "day sheet / production report",
        "deposit bag or lockbox",
        "tomorrow's schedule printout",
        "voicemail system access"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Reconcile the day's production, collections and adjustments against the schedule and payment records.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Balance the day sheet"
        },
        {
          "detail": "Does the day sheet balance?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "balances",
              "label": "Balances"
            },
            {
              "goto": "s8",
              "id": "off",
              "label": "Does not balance"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the day sheet balance?"
        },
        {
          "detail": "Count and bag the day's cash and checks for deposit, matching the total to the balanced day sheet.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Prepare the bank deposit"
        },
        {
          "detail": "A second person verifies the deposit total against the day sheet before it is secured for the bank.\n\nRecord: closing deposit log with two initials",
          "gate": {
            "ack": "I confirm I have completed this step as written: Second-person verification of the deposit.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "office-manager",
          "title": "Second-person verification of the deposit"
        },
        {
          "detail": "Print or pull up tomorrow's schedule, confirm which patients have confirmed, and flag any unconfirmed appointments for a morning follow-up call.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Print tomorrow's schedule and review confirmations"
        },
        {
          "detail": "Switch the phone system to the after-hours greeting and listen to confirm the recorded greeting is current and audible.\n\nWhy: A stale or garbled after-hours greeting means an urgent overnight call may not know what to do.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Set phones to night mode and verify voicemail greeting",
          "why": "A stale or garbled after-hours greeting means an urgent overnight call may not know what to do."
        },
        {
          "detail": "Front desk closing complete",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Front desk closing complete"
        },
        {
          "detail": "Notify billing/AR to trace the discrepancy before the deposit is finalized; do not adjust figures to force a match.\n\nWhy: Forcing a balance to close the day faster hides the real error and makes it much harder to trace later.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate an unbalanced day sheet to billing.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "billing",
          "title": "Escalate an unbalanced day sheet to billing",
          "why": "Forcing a balance to close the day faster hides the real error and makes it much harder to trace later."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Front desk closing routine — The last patient has checked out: day sheet balanced, deposit prepared, tomorrow's schedule printed and confirmations reviewed, phones to night mode, voicemail greeting verified.",
      "title": "Front desk closing routine",
      "trigger": "The last patient has checked out: day sheet balanced, deposit prepared, tomorrow's schedule printed and confirmations reviewed, phones to night mode, voicemail greeting verified",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — waterline flushing, sterilizer daily checks at open/close",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — waterline flushing, sterilizer daily checks at open/close",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "daily",
      "id": "oc-008",
      "kind": "operational",
      "materials": [
        "suction line cleaning solution",
        "sterilizer for last-cycle load",
        "handpiece lubrication/maintenance supplies",
        "waterline shutdown/treatment products per manufacturer"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Remove and bag all used instruments, disinfect and clean surfaces, restock consumables for the next day's first appointment.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Final operatory turnover"
        },
        {
          "detail": "Run the manufacturer-specified suction line cleaning solution through each vacuum line at end of day.\n\nWhy: Suction lines left uncleaned overnight can build up biofilm and odor, and this is the daily window to service them before they harden.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Clean suction lines",
          "why": "Suction lines left uncleaned overnight can build up biofilm and odor, and this is the daily window to service them before they harden."
        },
        {
          "detail": "Load and run the final sterilizer cycle of the day, and log the cycle's mechanical/chemical indicator result before securing the sterile stock.\n\nRecord: closing sterilizer cycle log",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Run and log the last sterilizer cycle"
        },
        {
          "detail": "Did the last cycle pass its indicator check?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "pass",
              "label": "Passed — secure sterile stock"
            },
            {
              "goto": "s10",
              "id": "fail",
              "label": "Failed indicator check"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Did the last cycle pass its indicator check?"
        },
        {
          "detail": "Lubricate and inspect handpieces per manufacturer instructions before they go through the final sterilization cycle or are stored for the next day.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Perform daily handpiece maintenance"
        },
        {
          "detail": "Perform the end-of-day waterline shutdown or treatment step specified by the unit manufacturer (e.g. air-purge or shutdown mode) to limit overnight biofilm growth.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Waterline shutdown procedure"
        },
        {
          "detail": "Turn off the central compressor and vacuum system once all clinical work for the day is finished.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Power off compressor and vacuum"
        },
        {
          "detail": "Report clinical-side closing completion (turnover done, suction lines cleaned, last sterilizer cycle logged, waterlines shut down, compressor off) to the office manager before leaving.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm clinical closing complete"
        },
        {
          "detail": "Clinical closing routine complete",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Clinical closing routine complete"
        },
        {
          "detail": "Quarantine the load, notify the office manager and dentist, and confirm the morning opening sterilizer check will re-verify the unit before any instrument from that load is used on a patient.\n\nWhy: A failed indicator on the last cycle of the day must not be discovered for the first time tomorrow morning with an operatory already stocked from that load.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate a failed closing sterilizer cycle.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "office-manager",
          "title": "Escalate a failed closing sterilizer cycle",
          "why": "A failed indicator on the last cycle of the day must not be discovered for the first time tomorrow morning with an operatory already stocked from that load."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Clinical closing routine (final turnover, suction lines, last sterilizer cycle, waterlines, compressor off) — The last patient is dismissed: final operatory turnover, suction line cleaning, last sterilizer cycle logged, waterline shutdown, handpiece maintenance, compressor and vacuum off.",
      "title": "Clinical closing routine (final turnover, suction lines, last sterilizer cycle, waterlines, compressor off)",
      "trigger": "The last patient is dismissed: final operatory turnover, suction line cleaning, last sterilizer cycle logged, waterline shutdown, handpiece maintenance, compressor and vacuum off",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens (sharps and exposure control at close)",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens (sharps and exposure control at close)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71-1301.76 controlled-substance physical security (locked at close)",
          "source": "DEA 21 CFR 1301.71-1301.76 controlled-substance physical security (locked at close)",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "Walkthrough checklist order (rooms, sharps, drugs, imaging, climate, lights, locks, alarm) — no vendor checklist reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent walkthrough checklist order (rooms, sharps, drugs, imaging, climate, lights, locks, alarm) — no vendor checklist reproduced"
          },
          "source": "Walkthrough checklist order (rooms, sharps, drugs, imaging, climate, lights, locks, alarm) — no vendor checklist reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 15,
      "frequency": "daily",
      "id": "oc-009",
      "kind": "operational",
      "materials": [
        "Closing checklist (paper or app)",
        "Alarm panel / code",
        "Controlled-substance log and key or lockbox code",
        "Building keys"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Walk every operatory, the waiting room, restrooms, and staff break room to confirm no patient or visitor remains in the building.\n\nWhy: Arming an alarm or locking a door with someone still inside is the most common closing failure.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm every operatory and common area is empty",
          "why": "Arming an alarm or locking a door with someone still inside is the most common closing failure."
        },
        {
          "detail": "Verify each operatory's sharps container is closed (not overfilled past the fill line) and any loose sharps from the day are disposed of, not left on a tray.\n\nWhy: OSHA 1910.1030 requires sharps containers be closed between uses and not accessible after hours.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Confirm sharps containers closed and stored",
          "why": "OSHA 1910.1030 requires sharps containers be closed between uses and not accessible after hours."
        },
        {
          "detail": "Confirm all controlled-substance stock is in the locked cabinet or safe, log the closing count against the running inventory, and note any discrepancy.\n\nWhy: DEA physical-security rules require controlled substances secured when the office is unattended, and a logged count is the earliest catch for a diversion problem.\n\nRecord: Closing controlled-substance count logged with initials and any discrepancy flagged",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Lock controlled substances and log the count",
          "why": "DEA physical-security rules require controlled substances secured when the office is unattended, and a logged count is the earliest catch for a diversion problem."
        },
        {
          "detail": "Switch off wall-mounted and portable x-ray units and confirm imaging computers are logged out or locked.\n\nWhy: Powered-down imaging equipment is safer overnight and protects patient image data from an unattended open session.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Power down x-ray and imaging units",
          "why": "Powered-down imaging equipment is safer overnight and protects patient image data from an unattended open session."
        },
        {
          "detail": "Set the thermostat to the overnight setpoint defined by the practice, and confirm any refrigerated medication or material is at the correct temperature and the fridge door is closed.\n\nWhy: A generic energy and cold-chain step; the practice defines its own setpoint, this protocol only requires it be checked, since no institute standard governs a specific number.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Set thermostat and check refrigerated items",
          "why": "A generic energy and cold-chain step; the practice defines its own setpoint, this protocol only requires it be checked, since no institute standard governs a specific number."
        },
        {
          "detail": "Switch off operatory lights, compressor, and vacuum if not already done in clinical closing; leave only security and emergency lighting on.\n\nWhy: Reduces fire risk and energy cost; equipment left running overnight is a common cause of premature wear.",
          "id": "s6",
          "kind": "step",
          "role": "all-staff",
          "title": "Turn off lights and equipment not needed overnight",
          "why": "Reduces fire risk and energy cost; equipment left running overnight is a common cause of premature wear."
        },
        {
          "detail": "Check and lock every exterior door and ground-floor window, including any back or side entrance used for deliveries.\n\nWhy: The back door is the door most often left unlocked because it is used the least during the closing rush.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Lock all exterior doors and windows",
          "why": "The back door is the door most often left unlocked because it is used the least during the closing rush."
        },
        {
          "detail": "Arm the alarm from the correct panel or app, confirm the arm signal before leaving, and note who was last out on the closing log.\n\nWhy: An unarmed system after the walkthrough defeats every prior step in this protocol.\n\nRecord: Closing log: walkthrough completed, alarm armed, last person out and time",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Arm the alarm system",
          "why": "An unarmed system after the walkthrough defeats every prior step in this protocol."
        },
        {
          "detail": "Closing walkthrough complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Closing walkthrough complete"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "End-of-day security and safety walkthrough — Last person out: operatories empty, sharps secured, controlled substances locked, x-ray units off, thermostat set, lights off, doors locked, alarm armed.",
      "title": "End-of-day security and safety walkthrough",
      "trigger": "Last person out: operatories empty, sharps secured, controlled substances locked, x-ray units off, thermostat set, lights off, doors locked, alarm armed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — dental unit waterline maintenance during periods of non-use",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — dental unit waterline maintenance during periods of non-use",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "generic",
          "label": "Multi-day shutdown checklist (waterlines, sterilizer, perishables, call coverage, climate) — no vendor checklist reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent multi-day shutdown checklist (waterlines, sterilizer, perishables, call coverage, climate) — no vendor checklist reproduced"
          },
          "source": "Multi-day shutdown checklist (waterlines, sterilizer, perishables, call coverage, climate) — no vendor checklist reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "oc-010",
      "kind": "operational",
      "materials": [
        "Multi-day shutdown checklist",
        "Waterline treatment product and manufacturer instructions",
        "Answering service / call-forwarding setup",
        "Emergency contact card for the on-call dentist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "office-manager",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the schedule to confirm the office will not open for two or more calendar days, including the closing day itself.\n\nWhy: Dental unit waterlines and other systems need different handling for a short overnight gap versus a multi-day closure.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the office will be closed two or more consecutive days",
          "why": "Dental unit waterlines and other systems need different handling for a short overnight gap versus a multi-day closure."
        },
        {
          "detail": "Follow the waterline system manufacturer's instructions for a multi-day shutdown — this is typically a shock or maintenance treatment before closing and a flush before first patient at reopen.\n\nWhy: Water sitting stagnant in dental unit lines over multiple days promotes biofilm growth; CDC guidance requires waterlines be maintained to keep output water within safe limits.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Treat or drain dental unit waterlines per manufacturer instructions",
          "why": "Water sitting stagnant in dental unit lines over multiple days promotes biofilm growth; CDC guidance requires waterlines be maintained to keep output water within safe limits."
        },
        {
          "detail": "Run the sterilizer's final cycle, drain the reservoir per manufacturer instructions, and leave the door propped open to air-dry the chamber.\n\nWhy: Standing water left in a sterilizer over several days can promote scale buildup and microbial growth in the chamber.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Drain and shut down the sterilizer",
          "why": "Standing water left in a sterilizer over several days can promote scale buildup and microbial growth in the chamber."
        },
        {
          "detail": "Confirm refrigerated medications and dental materials are within date and the refrigerator will maintain temperature unattended; remove or use up any break-room perishables that will spoil.\n\nWhy: A multi-day closure is long enough for a refrigerator failure or expiring stock to go unnoticed until reopen.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Check perishables and refrigerated materials",
          "why": "A multi-day closure is long enough for a refrigerator failure or expiring stock to go unnoticed until reopen."
        },
        {
          "detail": "Confirm the phone system forwards to an answering service or the on-call dentist's number, and confirm the on-call dentist knows the shutdown dates.\n\nWhy: A dental emergency does not pause for a holiday; patients need a working path to reach care even while the office is closed.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify emergency line forwarding and after-hours coverage",
          "why": "A dental emergency does not pause for a holiday; patients need a working path to reach care even while the office is closed."
        },
        {
          "detail": "Set the thermostat to the practice's defined multi-day setpoint (wider range than an overnight setting) to protect equipment and materials from temperature extremes.\n\nWhy: A multi-day closure tolerates a wider energy-saving setpoint than a single overnight closing, but extremes can damage sensitive dental materials.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Set HVAC for an unattended multi-day period",
          "why": "A multi-day closure tolerates a wider energy-saving setpoint than a single overnight closing, but extremes can damage sensitive dental materials."
        },
        {
          "detail": "Complete the standard end-of-day security and safety walkthrough (operatories empty, sharps secured, controlled substances locked, doors locked, alarm armed) in addition to the multi-day items above.\n\nWhy: A multi-day shutdown does not replace the daily security walkthrough — it adds to it.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the end-of-day security walkthrough",
          "why": "A multi-day shutdown does not replace the daily security walkthrough — it adds to it."
        },
        {
          "detail": "Record who completed each shutdown item and the date/time, filed with the closing log.\n\nRecord: Multi-day shutdown checklist with initials and timestamp per item",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the shutdown checklist as complete"
        },
        {
          "detail": "Multi-day shutdown complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Multi-day shutdown complete"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Multi-day shutdown before a weekend or holiday — The office is closing for two or more days: waterlines treated/drained per manufacturer, sterilizer drained, perishables checked, emergency line forwarding verified, HVAC set.",
      "title": "Multi-day shutdown before a weekend or holiday",
      "trigger": "The office is closing for two or more days: waterlines treated/drained per manufacturer, sterilizer drained, perishables checked, emergency line forwarding verified, HVAC set",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — waterline flushing and testing, sterilizer biological monitoring",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) + 2016 Summary — waterline flushing and testing, sterilizer biological monitoring",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control — sterilizer biological (spore) monitoring at least weekly and after any period of non-use",
          "source": "CDC Guidelines for Infection Control — sterilizer biological (spore) monitoring at least weekly and after any period of non-use",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71-1301.76 controlled-substance security (verify integrity of storage after closure)",
          "source": "DEA 21 CFR 1301.71-1301.76 controlled-substance security (verify integrity of storage after closure)",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "oc-011",
      "kind": "operational",
      "materials": [
        "Reopening checklist",
        "Waterline test strips or dip-slide test",
        "Biological indicator (spore test) and incubator/mail-in service",
        "Expiration-date sweep list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "sterilization-tech",
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the shutdown date and today's date; this protocol applies once the office has been closed a week or more (vacation, disaster, or renovation).\n\nWhy: A short weekend closure uses the lighter shutdown/reopen pair; a week or more of stagnation changes the water-quality and sterility risk enough to require testing before use.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the closure was a week or longer",
          "why": "A short weekend closure uses the lighter shutdown/reopen pair; a week or more of stagnation changes the water-quality and sterility risk enough to require testing before use."
        },
        {
          "detail": "Run each waterline for the manufacturer-recommended flush time before connecting any handpiece or syringe to a patient.\n\nWhy: Stagnant water over an extended closure allows biofilm to build; flushing clears standing water before testing and use.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Flush dental unit waterlines before any patient use",
          "why": "Stagnant water over an extended closure allows biofilm to build; flushing clears standing water before testing and use."
        },
        {
          "detail": "Does the waterline test pass the practice's water-quality threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "waterline-pass",
              "label": "Test passes — proceed to sterilizer check"
            },
            {
              "goto": "s11",
              "id": "waterline-fail",
              "label": "Test fails — re-treat and hold clinical use of that line"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Does the waterline test pass the practice's water-quality threshold?"
        },
        {
          "detail": "Run a biological indicator load and confirm a pass (via in-office incubator or mail-in service) before releasing any sterilized instrument for patient use.\n\nWhy: CDC guidance calls for biological monitoring after any period the sterilizer sat unused, since a sterilizer's mechanical performance is not confirmed by time alone.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Run a sterilizer biological indicator (spore test) before first clinical use",
          "why": "CDC guidance calls for biological monitoring after any period the sterilizer sat unused, since a sterilizer's mechanical performance is not confirmed by time alone."
        },
        {
          "detail": "The dentist or delegated licensed clinical lead confirms the biological indicator passed and the sterilizer log is complete before any instrument from this load is used on a patient.\n\nWhy: Releasing instruments on an unverified sterilizer after an extended shutdown carries direct infection-control risk to the first patients seen.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before instruments are released for patient use.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before instruments are released for patient use",
          "why": "Releasing instruments on an unverified sterilizer after an extended shutdown carries direct infection-control risk to the first patients seen."
        },
        {
          "detail": "Check expiration dates on local anesthetic, emergency drug kit contents, and any consumable stock that may have expired during the closure; pull and replace anything expired.\n\nWhy: A closure of a week or more is long enough for near-expiry stock to lapse while unused.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Sweep drug and supply expiration dates",
          "why": "A closure of a week or more is long enough for near-expiry stock to lapse while unused."
        },
        {
          "detail": "Confirm the controlled-substance lock or safe was not disturbed while closed and reconcile the count against the closing log.\n\nWhy: An extended closure with an empty building is a window where a storage breach could go unnoticed until reopen.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify controlled-substance storage integrity",
          "why": "An extended closure with an empty building is a window where a storage breach could go unnoticed until reopen."
        },
        {
          "detail": "Turn off after-hours forwarding, return every voicemail and portal message that accumulated during the closure, and update the phone greeting for normal hours.\n\nWhy: Patients who tried to reach the office during the closure need a same-day callback on reopen, not a silent backlog.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Resume normal phone routing and clear the message backlog",
          "why": "Patients who tried to reach the office during the closure need a same-day callback on reopen, not a silent backlog."
        },
        {
          "detail": "File the completed reopening checklist with waterline test result, biological indicator result, sign-off, and expiration sweep findings.\n\nRecord: Reopening checklist with waterline result, BI result, licensed sign-off, expiration sweep findings",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the reopening checklist as complete"
        },
        {
          "detail": "Reopening complete, cleared for patient care",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Reopening complete, cleared for patient care"
        },
        {
          "detail": "Take the failing line out of service, re-run the manufacturer's shock or maintenance treatment, and retest before returning it to patient use.\n\nWhy: A failed water-quality test means the line is not safe for patient contact until it passes.",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Re-treat and take the affected line out of clinical use",
          "why": "A failed water-quality test means the line is not safe for patient contact until it passes."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Reopening after an extended closure (vacation, disaster, renovation) — The office reopens after a week or more closed: flush and test waterlines, run a sterilizer biological indicator before use, sweep drug and supply expirations, resume phones and messaging.",
      "title": "Reopening after an extended closure (vacation, disaster, renovation)",
      "trigger": "The office reopens after a week or more closed: flush and test waterlines, run a sterilizer biological indicator before use, sweep drug and supply expirations, resume phones and messaging",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens exposure control plan (annual review; the daily huddle is where a same-day exposure or medical-alert item gets a same-day callout)",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens exposure control plan (annual review; the daily huddle is where a same-day exposure or medical-alert item gets a same-day callout)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "Daily huddle format: time-boxed agenda covering schedule review, production goal, medical alerts, lab-case status, schedule openings, and new-patient flags — no consultancy huddle system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent daily huddle format: time-boxed agenda covering schedule review, production goal, medical alerts, lab-case status, schedule openings, and new-patient flags — no consultancy huddle system reproduced"
          },
          "source": "Daily huddle format: time-boxed agenda covering schedule review, production goal, medical alerts, lab-case status, schedule openings, and new-patient flags — no consultancy huddle system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 10,
      "frequency": "daily",
      "id": "oc-012",
      "kind": "operational",
      "materials": [
        "Printed or on-screen day schedule",
        "Huddle agenda template",
        "Production goal for the day"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "office-manager",
        "front-desk",
        "hygienist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "All clinical and front-office staff working that day meet in one place (chairside, break room, or video call for remote roles) ten minutes before the first scheduled patient.\n\nWhy: A huddle held after patients start arriving gets rushed or skipped; the fixed pre-patient slot protects it.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather the whole team ten minutes before the first patient",
          "why": "A huddle held after patients start arriving gets rushed or skipped; the fixed pre-patient slot protects it."
        },
        {
          "detail": "Walk the day's schedule column by column: patient count, procedure types, new patients, and any double-bookings or tight turns.\n\nWhy: Everyone on the team needs the same picture of the day before it starts, not just their own column.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Review today's schedule end to end",
          "why": "Everyone on the team needs the same picture of the day before it starts, not just their own column."
        },
        {
          "detail": "State the target for the day (production dollar goal, hygiene reappointment rate, or whatever metric the practice tracks) so the team knows what today is measured against.\n\nWhy: A team that does not know the goal cannot work toward it during the day.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "State the day's production or scheduling goal",
          "why": "A team that does not know the goal cannot work toward it during the day."
        },
        {
          "detail": "The clinical lead calls out any patient today with a medical alert (allergy, anticoagulant, cardiac history, anxiety flag) that changes chairside handling.\n\nWhy: A verbal callout in the huddle catches an alert before the patient is in the chair, when it is easiest to plan around.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Call out medical alerts for today's patients",
          "why": "A verbal callout in the huddle catches an alert before the patient is in the chair, when it is easiest to plan around."
        },
        {
          "detail": "Confirm every lab case scheduled for delivery today has arrived and matches the patient and procedure on the schedule.\n\nWhy: A missing lab case discovered at huddle time can still be chased down before the patient arrives; discovered chairside, it cannot.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm lab case status for today's seat/delivery appointments",
          "why": "A missing lab case discovered at huddle time can still be chased down before the patient arrives; discovered chairside, it cannot."
        },
        {
          "detail": "Call out any open chair time today and assign a specific person to work the recall list, waitlist, or same-day opportunities to fill it.\n\nWhy: An opening named but not assigned to anyone tends to stay open.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify schedule openings and assign who will work them",
          "why": "An opening named but not assigned to anyone tends to stay open."
        },
        {
          "detail": "Call out each new patient on today's schedule, their chief concern, and how they found the practice.\n\nWhy: Knowing the referral source in advance lets the team acknowledge it with the patient and track what is bringing patients in.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag new patients and their referral source",
          "why": "Knowing the referral source in advance lets the team acknowledge it with the patient and track what is bringing patients in."
        },
        {
          "detail": "Huddle complete, team disperses to open",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Huddle complete, team disperses to open"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Daily morning huddle (10 minutes, whole team) — Ten minutes before the first patient on every clinical day — schedule, goal, medical alerts, lab cases, openings, new patients.",
      "title": "Daily morning huddle (10 minutes, whole team)",
      "trigger": "Ten minutes before the first patient on every clinical day — schedule, goal, medical alerts, lab cases, openings, new patients",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens requires a documented, periodically reviewed exposure-control plan; cited here as this class's regulatory-floor citation for recurring management meetings, not as a claim that every weekly meeting itself performs that review (when it does, log it as the specific agenda item).",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens requires a documented, periodically reviewed exposure-control plan; cited here as this class's regulatory-floor citation for recurring management meetings, not as a claim that every weekly meeting itself performs that review (when it does, log it as the specific agenda item).",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "Weekly team meeting format: prior-week review, current issues, training moment, action items — no consultancy meeting system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent weekly team meeting format: prior-week review, current issues, training moment, action items — no consultancy meeting system reproduced"
          },
          "source": "Weekly team meeting format: prior-week review, current issues, training moment, action items — no consultancy meeting system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 45,
      "frequency": "weekly",
      "id": "oc-013",
      "kind": "operational",
      "materials": [
        "Weekly meeting agenda template",
        "Prior week's KPI snapshot",
        "Open action-item list from the last meeting"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm no patients are booked over the fixed weekly meeting block; the front desk does not schedule patients into this time.\n\nWhy: A meeting slot that gets booked over during a busy week stops happening; a protected block is what makes the cadence real.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the weekly slot is protected on the schedule",
          "why": "A meeting slot that gets booked over during a busy week stops happening; a protected block is what makes the cadence real."
        },
        {
          "detail": "Move to a room where the team will not be interrupted and set phones to voicemail or hand off coverage to whoever is not attending.\n\nWhy: A meeting interrupted every few minutes by the phone does not produce useful discussion or decisions.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Close the doors, phones to voicemail",
          "why": "A meeting interrupted every few minutes by the phone does not produce useful discussion or decisions."
        },
        {
          "detail": "Walk through the prior week's numbers (production, collections, new patients, hygiene reappointment) and status-check every open action item from the last meeting.\n\nWhy: A weekly meeting that never revisits last week's commitments trains the team that action items are optional.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Review last week's KPI snapshot and open action items",
          "why": "A weekly meeting that never revisits last week's commitments trains the team that action items are optional."
        },
        {
          "detail": "Open the floor for issues team members flag (workflow friction, supply needs, upcoming staffing gaps) and review any unusual scheduling coming up (holidays, provider time off).\n\nWhy: The weekly meeting is the forum for issues too broad for a daily huddle to solve on the spot.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Discuss current issues and upcoming schedule needs",
          "why": "The weekly meeting is the forum for issues too broad for a daily huddle to solve on the spot."
        },
        {
          "detail": "Spend five to ten minutes on a single training topic or protocol change — a new form, a clinical update, or a reminder on an existing procedure.\n\nWhy: Bundling ongoing training into the existing weekly meeting avoids the cost of scheduling separate training sessions for small updates.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Deliver a short training or protocol-update moment",
          "why": "Bundling ongoing training into the existing weekly meeting avoids the cost of scheduling separate training sessions for small updates."
        },
        {
          "detail": "Write down every new commitment made during the meeting with a named owner and a target date, using the standard meeting action-item tracking protocol.\n\nWhy: An action item without an owner and date is a wish, not a commitment.\n\nRecord: Weekly meeting minutes and action-item list, owners and dates",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Capture new action items with owner and date",
          "why": "An action item without an owner and date is a wish, not a commitment."
        },
        {
          "detail": "Weekly team meeting complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Weekly team meeting complete"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Weekly team meeting (30-60 minutes, doors closed) — The fixed weekly slot blocked on the schedule arrives.",
      "title": "Weekly team meeting (30-60 minutes, doors closed)",
      "trigger": "The fixed weekly slot blocked on the schedule arrives",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; cited only to establish that the class's routines rest on documented regulatory practice, not as a claim this one-on-one reviews controlled-substance security (that review sits in the end-of-day walkthrough, oc-009).",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; cited only to establish that the class's routines rest on documented regulatory practice, not as a claim this one-on-one reviews controlled-substance security (that review sits in the end-of-day walkthrough, oc-009).",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "Four-quadrant one-on-one agenda (numbers, people, patients, problems) — no consultancy meeting system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent four-quadrant one-on-one agenda (numbers, people, patients, problems) — no consultancy meeting system reproduced"
          },
          "source": "Four-quadrant one-on-one agenda (numbers, people, patients, problems) — no consultancy meeting system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "weekly",
      "id": "oc-014",
      "kind": "operational",
      "materials": [
        "One-on-one agenda template (financials / staffing / patient issues / open decisions)",
        "Week's KPI snapshot",
        "Open decision list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm the standing 30-minute owner-office manager meeting is on both calendars and not overridden by a patient or vendor appointment.\n\nWhy: This is the one meeting where the two people who run the business day-to-day sync privately; it is the first slot people try to give away.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the fixed weekly slot",
          "why": "This is the one meeting where the two people who run the business day-to-day sync privately; it is the first slot people try to give away."
        },
        {
          "detail": "Review week-to-date production, collections, and accounts receivable aging against the month's goal.\n\nWhy: A weekly numbers check catches a collections or production drift early enough to correct within the month.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Review financials",
          "why": "A weekly numbers check catches a collections or production drift early enough to correct within the month."
        },
        {
          "detail": "Discuss staffing status: coverage gaps, performance concerns, upcoming time-off requests, and any HR items needing the owner's decision.\n\nWhy: Staffing problems compound if they wait for a monthly or quarterly meeting to surface.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Review staffing",
          "why": "Staffing problems compound if they wait for a monthly or quarterly meeting to surface."
        },
        {
          "detail": "Discuss patient-experience issues, complaints received that week, and any case that needs the owner's clinical or financial judgment.\n\nWhy: A complaint or difficult case is easiest to resolve well while it is fresh, not deferred to the monthly meeting.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review patient issues",
          "why": "A complaint or difficult case is easiest to resolve well while it is fresh, not deferred to the monthly meeting."
        },
        {
          "detail": "Walk the open decision list — anything blocked on the owner — and make a call on each item rather than deferring it again.\n\nWhy: The office manager can only execute as fast as the owner decides; a one-on-one that defers everything again defeats its purpose.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review open decisions and make decisions",
          "why": "The office manager can only execute as fast as the owner decides; a one-on-one that defers everything again defeats its purpose."
        },
        {
          "detail": "Record each decision made and any resulting action items with owner and date.\n\nRecord: One-on-one notes: decisions made, action items, owner and date",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log decisions and any new action items"
        },
        {
          "detail": "One-on-one complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "One-on-one complete"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Weekly owner-office manager one-on-one (financials, staffing, patient issues, open decisions) — The fixed weekly 30-minute meeting between owner and office manager.",
      "title": "Weekly owner-office manager one-on-one (financials, staffing, patient issues, open decisions)",
      "trigger": "The fixed weekly 30-minute meeting between owner and office manager",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens ties PPE and exposure-control compliance to documented review; cited as this class's regulatory-floor citation for recurring department check-ins, not as a claim this specific check-in agenda covers PPE compliance.",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens ties PPE and exposure-control compliance to documented review; cited as this class's regulatory-floor citation for recurring department check-ins, not as a claim this specific check-in agenda covers PPE compliance.",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "Department check-in format: workload, blockers, one metric, one development topic — no consultancy meeting system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent department check-in format: workload, blockers, one metric, one development topic — no consultancy meeting system reproduced"
          },
          "source": "Department check-in format: workload, blockers, one metric, one development topic — no consultancy meeting system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 15,
      "frequency": "weekly",
      "id": "oc-015",
      "kind": "operational",
      "materials": [
        "Department check-in agenda",
        "Department-specific metric snapshot"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk",
        "hygienist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm the standing weekly slot with the front-office, hygiene, or assisting lead is on both calendars.\n\nWhy: A short, frequent check-in surfaces small department issues before they become a bigger problem raised at the monthly meeting.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the fifteen-minute check-in with the department lead",
          "why": "A short, frequent check-in surfaces small department issues before they become a bigger problem raised at the monthly meeting."
        },
        {
          "detail": "Ask what is on the department's plate this week and whether staffing and time are adequate for it.\n\nWhy: A department lead closest to the daily work sees capacity strain before it shows up in the numbers.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the department's current workload",
          "why": "A department lead closest to the daily work sees capacity strain before it shows up in the numbers."
        },
        {
          "detail": "Ask what is blocking the department lead from doing their job well this week, and note what the office manager can remove.\n\nWhy: A department lead check-in that never asks about blockers becomes a status report instead of a working conversation.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify blockers the department needs help clearing",
          "why": "A department lead check-in that never asks about blockers becomes a status report instead of a working conversation."
        },
        {
          "detail": "Review one metric relevant to the department (e.g. hygiene reappointment rate, front-desk answer rate, chair turnover time) and discuss the trend.\n\nWhy: One focused metric per check-in keeps the conversation actionable instead of a full data dump.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Review one department-specific metric",
          "why": "One focused metric per check-in keeps the conversation actionable instead of a full data dump."
        },
        {
          "detail": "Spend a minute on something the department lead or a team member did well, or a development need to bring to the owner.\n\nWhy: A check-in that is only problems and metrics erodes over time; recognition and development keep it a conversation people want to have.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Note a development or recognition item",
          "why": "A check-in that is only problems and metrics erodes over time; recognition and development keep it a conversation people want to have."
        },
        {
          "detail": "Note any action item from the check-in with an owner and date.\n\nRecord: Department check-in notes and any action items",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log any action items from the check-in"
        },
        {
          "detail": "Department check-in complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Department check-in complete"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Department lead check-in (front office, hygiene, assisting) — Weekly 15-minute check-in with each department lead.",
      "title": "Department lead check-in (front office, hygiene, assisting)",
      "trigger": "Weekly 15-minute check-in with each department lead",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "No DEA or other regulatory authority requires or governs a monthly business-KPI scorecard meeting — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No DEA or other regulatory authority requires or governs a monthly business-KPI scorecard meeting — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "21 CFR §1304.11's own text is exclusively about the biennial physical inventory of controlled substances on hand (\"Every person required to keep records shall take an inventory ... at least every two years ... a complete and accurate record of all controlled substances on hand\"). It says nothing about production, collections, hygiene, or any general KPI scorecard, and it sets a two-year cadence, not a monthly one — so it cannot even serve as a 'regulatory-floor cadence' analogy for a monthly meeting.",
            "ticket": "PROT-017",
            "was": {
              "source": "21 CFR §1304.11 (Part 1304, Records and Reports of Registrants)",
              "url": "https://www.ecfr.gov/current/title-21/chapter-II/part-1304/subject-group-ECFR9944e94ba5f1eb0/section-1304.11"
            }
          },
          "source": "No DEA or other regulatory authority requires or governs a monthly business-KPI scorecard meeting — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Monthly KPI scorecard meeting (production, collections, new patients, case acceptance, hygiene reappointment, AR aging) — no consultancy scorecard system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent monthly KPI scorecard meeting (production, collections, new patients, case acceptance, hygiene reappointment, AR aging) — no consultancy scorecard system reproduced"
          },
          "source": "Monthly KPI scorecard meeting (production, collections, new patients, case acceptance, hygiene reappointment, AR aging) — no consultancy scorecard system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "oc-016",
      "kind": "operational",
      "materials": [
        "Monthly KPI scorecard",
        "Prior month's action items",
        "Month-end financial close report",
        "Production, collections, and case-acceptance reports"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "billing",
        "treatment-coordinator",
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the prior month's books are closed and the production, collections, and AR reports are final before the meeting.\n\nWhy: Reviewing numbers before the close is final wastes the meeting on figures that will change.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Confirm month-end financial close is complete",
          "why": "Reviewing numbers before the close is final wastes the meeting on figures that will change."
        },
        {
          "detail": "Review each KPI on the scorecard (production, collections rate, new patients, case acceptance, hygiene reappointment, AR aging) against its target and prior month.\n\nWhy: A single scorecard reviewed the same way every month makes month-over-month drift visible instead of buried in narrative.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Walk the KPI scorecard against target",
          "why": "A single scorecard reviewed the same way every month makes month-over-month drift visible instead of buried in narrative."
        },
        {
          "detail": "Are any KPIs below target this month?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "on-target",
              "label": "All KPIs at or above target"
            },
            {
              "goto": "s8",
              "id": "below-target",
              "label": "One or more KPIs below target"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Are any KPIs below target this month?"
        },
        {
          "detail": "Status-check every action item assigned at last month's numbers meeting.\n\nWhy: The monthly meeting is the checkpoint where longer-cycle commitments get closed out or explicitly re-committed.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Review status of prior month's action items",
          "why": "The monthly meeting is the checkpoint where longer-cycle commitments get closed out or explicitly re-committed."
        },
        {
          "detail": "The practice owner reviews the finalized scorecard and any corrective actions before they are logged as the month's record and communicated to the team.\n\nWhy: The monthly scorecard often informs compensation, staffing, and spending decisions, so the owner reviews it before it is treated as settled.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review before the scorecard is finalized.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review before the scorecard is finalized",
          "why": "The monthly scorecard often informs compensation, staffing, and spending decisions, so the owner reviews it before it is treated as settled."
        },
        {
          "detail": "File the reviewed scorecard, root-cause notes, and new action items with owners and dates.\n\nRecord: Monthly KPI scorecard, root-cause notes, action items with owners and dates",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the scorecard and new action items"
        },
        {
          "detail": "Monthly numbers meeting complete",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Monthly numbers meeting complete"
        },
        {
          "detail": "For each KPI below target, discuss the likely cause with the relevant department lead present (e.g. treatment coordinator for case acceptance, hygienist for reappointment rate) and agree a corrective action.\n\nWhy: A KPI named as below-target without a root-cause discussion tends to repeat next month.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Discuss root cause for each below-target KPI",
          "why": "A KPI named as below-target without a root-cause discussion tends to repeat next month."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Monthly numbers meeting (KPI scorecard review) — First week of the month, after month-end close.",
      "title": "Monthly numbers meeting (KPI scorecard review)",
      "trigger": "First week of the month, after month-end close",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens establishes the dated, retained-review recordkeeping discipline this class's regulatory floor sets for any standing clinical-consistency meeting; this protocol's own content is perio/exam calibration, not bloodborne-pathogen exposure control.",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens establishes the dated, retained-review recordkeeping discipline this class's regulatory floor sets for any standing clinical-consistency meeting; this protocol's own content is perio/exam calibration, not bloodborne-pathogen exposure control.",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "oc-017",
      "kind": "operational",
      "materials": [
        "calibration case list",
        "de-identified chart excerpts for discussion",
        "agenda template",
        "action-item log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Before the meeting, office manager pulls any cases flagged in the prior month where hygienist findings (perio charting, radiographic read) and the dentist exam findings diverged, or where a referral threshold was questioned.\n\nWhy: A dated list keeps the meeting focused on real cases instead of general debate.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the disagreement case list",
          "why": "A dated list keeps the meeting focused on real cases instead of general debate."
        },
        {
          "detail": "Case list uses chart number or initials only, not full patient name, DOB, or address, when shared in the pre-read.\n\nWhy: PHI minimization for anything that leaves the clinical record system.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "De-identify case references",
          "why": "PHI minimization for anything that leaves the clinical record system."
        },
        {
          "detail": "Dentist orders the case list by clinical significance, adds any new referral-threshold questions (e.g. perio probing depth cutoffs for specialist referral), and time-boxes each item.\n\nWhy: Calibration meetings drift without a forced order and clock.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Set the agenda",
          "why": "Calibration meetings drift without a forced order and clock."
        },
        {
          "detail": "For each case: hygienist restates the finding and rationale; dentist restates the exam finding and rationale; both name what evidence would change their read; agreement or documented disagreement is recorded.\n\nWhy: Structured turn-taking prevents seniority alone from settling clinical questions.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Walk each case",
          "why": "Structured turn-taking prevents seniority alone from settling clinical questions."
        },
        {
          "detail": "Was a referral threshold or documentation standard changed?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-change",
              "label": "No standard changed, only case-level notes"
            },
            {
              "goto": "s8",
              "id": "changed",
              "label": "A threshold or documentation standard changed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Was a referral threshold or documentation standard changed?"
        },
        {
          "detail": "Meeting log records each case's resolution, any standard changed, and open action items with an owner and date, filed in the practice's meeting record system.\n\nRecord: Calibration meeting log: case outcomes, standards changed, action items with owner/date",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log outcomes and action items"
        },
        {
          "detail": "Calibration meeting closed",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Calibration meeting closed"
        },
        {
          "detail": "Dentist gives an explicit sign-off on the exact new wording of the referral threshold or documentation standard before it is handed off for rollout.\n\nWhy: A referral threshold governs when a patient is sent to a specialist; it does not become a standard on an informal verbal nod in a meeting.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the new referral threshold before it leaves the room.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the new referral threshold before it leaves the room",
          "why": "A referral threshold governs when a patient is sent to a specialist; it does not become a standard on an informal verbal nod in a meeting."
        },
        {
          "detail": "Office manager opens the protocol-change-rollout process (oc-022) so the updated threshold is trained, posted and dated before anyone is expected to follow it.\n\nWhy: A verbal agreement in a meeting is not a trained standard until it goes through rollout.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Route the change to protocol-change rollout",
          "why": "A verbal agreement in a meeting is not a trained standard until it goes through rollout."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Doctor–hygiene calibration meeting (perio, exam findings, referral thresholds) — Monthly, or whenever hygiene and doctor findings disagree on a case.",
      "title": "Doctor–hygiene calibration meeting (perio, exam findings, referral thresholds)",
      "trigger": "Monthly, or whenever hygiene and doctor findings disagree on a case",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; quarterly planning does not itself touch controlled-substance security.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; quarterly planning does not itself touch controlled-substance security.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 240,
      "frequency": "quarterly",
      "id": "oc-018",
      "kind": "operational",
      "materials": [
        "prior quarter numbers (production, collections, new patients, hygiene reappointment rate)",
        "goal template",
        "action-item log",
        "calendar for the coming quarter"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Office manager pulls aggregate production, collections, new-patient count, hygiene reappointment rate, and case-acceptance rate for the closing quarter, no patient-level detail.\n\nWhy: Planning without the actual numbers turns into opinion.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Assemble prior-quarter numbers",
          "why": "Planning without the actual numbers turns into opinion."
        },
        {
          "detail": "Owner and dentist compare the goals set last quarter to what actually happened, naming what worked and what did not.\n\nWhy: Closing the loop on old goals before setting new ones prevents repeating the same miss.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review prior goals against results",
          "why": "Closing the loop on old goals before setting new ones prevents repeating the same miss."
        },
        {
          "detail": "Owner, office manager and dentist agree on a short list of specific, measurable goals (e.g. hygiene reappointment rate target, new-patient count, a system fix) rather than a long wish list.\n\nWhy: A short list gets tracked; a long list gets ignored.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set 3-5 goals for the coming quarter",
          "why": "A short list gets tracked; a long list gets ignored."
        },
        {
          "detail": "Each goal gets a named owner and a mid-quarter checkpoint date, not just an end-of-quarter deadline.\n\nWhy: A goal with no checkpoint is rediscovered as a miss instead of course-corrected.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign an owner and checkpoint date to each goal",
          "why": "A goal with no checkpoint is rediscovered as a miss instead of course-corrected."
        },
        {
          "detail": "Known events (CE courses, planned closures, equipment service, marketing pushes) are placed on the shared calendar before the quarter begins.\n\nWhy: Scheduling collisions found in week one of a quarter are avoidable in the planning session.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Block the coming quarter's calendar",
          "why": "Scheduling collisions found in week one of a quarter are avoidable in the planning session."
        },
        {
          "detail": "Quarterly goals, owners, checkpoint dates and calendar blocks recorded in the practice's planning document.\n\nRecord: Quarterly plan: goals, owners, checkpoints, calendar blocks",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the plan"
        },
        {
          "detail": "Quarterly planning session closed",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Quarterly planning session closed"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Quarterly planning and goal reset (half day) — Once per quarter, before the new quarter starts.",
      "title": "Quarterly planning and goal reset (half day)",
      "trigger": "Once per quarter, before the new quarter starts",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; annual budget and goal-setting does not itself touch controlled-substance security.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; annual budget and goal-setting does not itself touch controlled-substance security.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 480,
      "frequency": "annual",
      "id": "oc-019",
      "kind": "operational",
      "materials": [
        "prior-year financial summary",
        "annual budget template",
        "training-plan template",
        "holiday and closure calendar",
        "team roster"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Office manager compiles year-end aggregate production, collections, overhead ratio, new-patient count, and staffing changes, no patient-level detail.\n\nWhy: The annual day sets next year's numbers against last year's actuals, not guesses.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare the prior-year summary",
          "why": "The annual day sets next year's numbers against last year's actuals, not guesses."
        },
        {
          "detail": "Owner walks the prior year's goals and budget line by line against what happened, with the whole team present for context they can act on.\n\nWhy: Team buy-in for next year's plan is higher when the team sees the review, not just the new targets.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the year against last year's plan",
          "why": "Team buy-in for next year's plan is higher when the team sees the review, not just the new targets."
        },
        {
          "detail": "Owner and office manager set the coming year's budget by category (staffing, supplies, equipment, marketing, CE), using overhead-ratio benchmarks as a sanity check, not a fixed formula.\n\nWhy: A budget without benchmarks drifts toward whatever was easiest to defend the prior year.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set the annual budget",
          "why": "A budget without benchmarks drifts toward whatever was easiest to defend the prior year."
        },
        {
          "detail": "3-5 top-level annual goals are set, each later broken into the quarterly goals used in oc-018.\n\nWhy: Annual goals without a quarterly cascade are reviewed once a year and forgotten in between.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set annual goals cascading from the budget",
          "why": "Annual goals without a quarterly cascade are reviewed once a year and forgotten in between."
        },
        {
          "detail": "Each team member's required continuing education, license renewal dates, and any planned cross-training or new-skill goals are listed with target dates.\n\nWhy: License lapses and skipped CE are cheaper to catch on an annual calendar than discovered at renewal time.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the training plan",
          "why": "License lapses and skipped CE are cheaper to catch on an annual calendar than discovered at renewal time."
        },
        {
          "detail": "Planned holidays, staff vacation blocks, and any known multi-day closures are placed on the shared annual calendar.\n\nWhy: Early calendar-blocking avoids double-booking staff time off against patient scheduling.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the year's closure and holiday calendar",
          "why": "Early calendar-blocking avoids double-booking staff time off against patient scheduling."
        },
        {
          "detail": "Budget, goals, training plan and calendar recorded in the practice's annual planning document, shared with the team.\n\nRecord: Annual plan: budget, goals, training plan, closure calendar",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the annual plan"
        },
        {
          "detail": "Annual planning day closed",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Annual planning day closed"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Annual planning day (budget, goals, calendar, training plan) — Once a year, before the fiscal year starts.",
      "title": "Annual planning day (budget, goals, calendar, training plan)",
      "trigger": "Once a year, before the fiscal year starts",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens (sharps and exposure control at open/close)",
          "source": "OSHA 29 CFR 1910.1030 Bloodborne Pathogens (sharps and exposure control at open/close)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "oc-020",
      "kind": "operational",
      "materials": [
        "incident report form",
        "OSHA exposure log if applicable",
        "debrief notes template",
        "action-item log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Office manager confirms the underlying incident (emergency, complaint, exposure, near-miss) already has its own incident report or OSHA exposure log entry filed before scheduling the debrief.\n\nWhy: The debrief is a learning conversation, not the record of what happened; that record must already exist.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the incident report exists first",
          "why": "The debrief is a learning conversation, not the record of what happened; that record must already exist."
        },
        {
          "detail": "Debrief is scheduled and all directly involved staff notified within 48 hours of the incident, while details are still fresh.\n\nWhy: Delay degrades recall and lets informal, uncorrected accounts spread among staff first.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the debrief within 48 hours",
          "why": "Delay degrades recall and lets informal, uncorrected accounts spread among staff first."
        },
        {
          "detail": "Compliance officer confirms any legally required reporting (e.g. OSHA exposure follow-up, board complaint response) is already assigned and on track before the team debrief proceeds as a learning session.\n\nWhy: A team debrief must never be treated as satisfying a separate regulatory reporting obligation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm any required regulatory reporting is separately in motion.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm any required regulatory reporting is separately in motion",
          "why": "A team debrief must never be treated as satisfying a separate regulatory reporting obligation."
        },
        {
          "detail": "Facilitator asks: what happened, in sequence; what went as trained; what did not; what would change the outcome next time; is this a one-off or a pattern.\n\nWhy: A fixed neutral question set keeps the debrief about the process, not about blaming an individual.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the debrief with a fixed question set",
          "why": "A fixed neutral question set keeps the debrief about the process, not about blaming an individual."
        },
        {
          "detail": "Does the debrief surface a corrective action?",
          "forks": [
            {
              "advised": false,
              "goto": "s7",
              "id": "no-action",
              "label": "No systemic gap found, isolated event"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "action-needed",
              "label": "A training gap or protocol gap is identified"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the debrief surface a corrective action?"
        },
        {
          "detail": "If the gap is a protocol or training issue, office manager opens protocol-change-rollout (oc-022) to update and retrain before the corrective action is considered complete.\n\nWhy: A debrief that ends in a discussion but no protocol change repeats the same incident.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Route the fix to protocol-change rollout",
          "why": "A debrief that ends in a discussion but no protocol change repeats the same incident."
        },
        {
          "detail": "Debrief notes record what was discussed at a process level, whether a corrective action was opened, and the action's owner and date; patient-identifying detail stays only in the original incident report.\n\nRecord: Debrief log: process findings, corrective action owner/date, link to incident report",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the debrief outcome"
        },
        {
          "detail": "Post-incident debrief closed",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Post-incident debrief closed"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Post-incident team debrief after an emergency, complaint, exposure or near-miss — Within 48 hours of any medical emergency, patient complaint, exposure or near-miss.",
      "title": "Post-incident team debrief after an emergency, complaint, exposure or near-miss",
      "trigger": "Within 48 hours of any medical emergency, patient complaint, exposure or near-miss",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; a generic action-item log does not itself touch controlled-substance security.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; a generic action-item log does not itself touch controlled-substance security.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "oc-021",
      "kind": "operational",
      "materials": [
        "shared action-item log (spreadsheet or board)",
        "meeting notes"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "During the meeting, office manager (or a designated notetaker) writes each action item verbatim into the shared log as it comes up, not from memory afterward.\n\nWhy: Items paraphrased after the fact drift from what was actually agreed.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Capture each action item as it is raised",
          "why": "Items paraphrased after the fact drift from what was actually agreed."
        },
        {
          "detail": "For each item: a single named owner (never 'the team'), a concrete due date (never 'soon'), and the meeting it came from.\n\nWhy: An item with no single owner is an item nobody does.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Every item gets an owner and a date",
          "why": "An item with no single owner is an item nobody does."
        },
        {
          "detail": "Facilitator reads the full action list back to the room at the end of the meeting so owners can correct or confirm what they heard.\n\nWhy: Confirming out loud catches mismatches before people leave the room.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Read the list back before the meeting ends",
          "why": "Confirming out loud catches mismatches before people leave the room."
        },
        {
          "detail": "Every recurring meeting (huddle, weekly, calibration, planning) opens by reviewing items still open from the prior log, before new business.\n\nWhy: An action log nobody reopens is a list, not a follow-through system.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Open the next meeting with the open list",
          "why": "An action log nobody reopens is a list, not a follow-through system."
        },
        {
          "detail": "Is an item overdue by more than one cycle?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "on-track",
              "label": "Item is on track or newly overdue"
            },
            {
              "goto": "s8",
              "id": "stale",
              "label": "Item has carried over more than one cycle unresolved"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is an item overdue by more than one cycle?"
        },
        {
          "detail": "Log is updated after every meeting: closed items marked done with date closed, open items carried forward with an updated status.\n\nRecord: Action-item log: item, owner, due date, status, source meeting",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the log status"
        },
        {
          "detail": "Action-item cycle closed for this meeting",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Action-item cycle closed for this meeting"
        },
        {
          "detail": "Office manager flags the stale item directly to the owner and, if still unresolved, to the practice owner, rather than letting it silently roll forward again.\n\nWhy: Silent rollover is how action logs become theater instead of a working system.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate a stale item to its owner's supervisor",
          "why": "Silent rollover is how action logs become theater instead of a working system."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Meeting action-item capture and follow-through — The end of every meeting: items assigned an owner and date, reviewed at the next meeting.",
      "title": "Meeting action-item capture and follow-through",
      "trigger": "The end of every meeting: items assigned an owner and date, reviewed at the next meeting",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; when a rolled-out change does touch controlled-substance handling it routes through this protocol's own licensed-signoff gate, not through this citation.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation; when a rolled-out change does touch controlled-substance handling it routes through this protocol's own licensed-signoff gate, not through this citation.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "oc-022",
      "kind": "operational",
      "materials": [
        "updated protocol/method document",
        "version log",
        "sign-off sheet or system",
        "posting location (physical or digital)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "The updated protocol or Method gets a new version number and a dated changelog line describing what changed and why.\n\nWhy: Untracked edits make it impossible to know which version any given staff member was trained on.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Version the updated document",
          "why": "Untracked edits make it impossible to know which version any given staff member was trained on."
        },
        {
          "detail": "Does the change touch a clinical, safety, or licensed-scope step?",
          "forks": [
            {
              "advised": false,
              "goto": "s4",
              "id": "operational-only",
              "label": "Change is operational only (scheduling, front-desk workflow)"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "clinical-safety",
              "label": "Change touches a clinical, safety or licensed-scope step"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the change touch a clinical, safety, or licensed-scope step?"
        },
        {
          "detail": "A licensed dentist reviews and signs off on the updated wording before it is posted or trained, whenever the change affects a clinical, safety, or licensed-scope step.\n\nWhy: A protocol change that reaches clinical practice without a licensed review can create a scope-of-practice or standard-of-care exposure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the clinical change before rollout.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the clinical change before rollout",
          "why": "A protocol change that reaches clinical practice without a licensed review can create a scope-of-practice or standard-of-care exposure."
        },
        {
          "detail": "The new version replaces the old one at its posting location (binder, shared drive, or protocol library), with the old version archived rather than deleted.\n\nWhy: Keeping the prior version archived lets a later question trace what was in effect on a given date.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Post the updated protocol",
          "why": "Keeping the prior version archived lets a later question trace what was in effect on a given date."
        },
        {
          "detail": "The change is not effective immediately; office manager sets an effective date that allows time for every affected role to be trained first.\n\nWhy: A same-day effective date with no training window guarantees the old and new versions are both being followed at once.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Set an effective date with lead time",
          "why": "A same-day effective date with no training window guarantees the old and new versions are both being followed at once."
        },
        {
          "detail": "Office manager (or the role's supervisor) walks the change with every staff member in an affected role, live or via a recorded walkthrough, before the effective date.\n\nWhy: Posting alone does not equal training; a document nobody reads is not a rolled-out change.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief each affected role",
          "why": "Posting alone does not equal training; a document nobody reads is not a rolled-out change."
        },
        {
          "detail": "Each affected staff member signs (physically or digitally) confirming they were trained on the change before the effective date.\n\nWhy: A dated, named sign-off is what makes 'the team was trained' verifiable later instead of asserted.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Collect sign-off from every affected staff member",
          "why": "A dated, named sign-off is what makes 'the team was trained' verifiable later instead of asserted."
        },
        {
          "detail": "Version number, effective date, licensed sign-off (if applicable), and staff sign-off completion recorded in the protocol's version log.\n\nRecord: Protocol version log: version, effective date, licensed sign-off, staff sign-off status",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the rollout"
        },
        {
          "detail": "Protocol change rolled out",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Protocol change rolled out"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Rolling out a changed protocol (method update) to the team — A protocol or method is edited and must be trained, posted and dated before it is followed.",
      "title": "Rolling out a changed protocol (method update) to the team",
      "trigger": "A protocol or method is edited and must be trained, posted and dated before it is followed",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; a weather/outage closure decision does not itself touch controlled-substance security.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; a weather/outage closure decision does not itself touch controlled-substance security.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "oc-023",
      "kind": "operational",
      "materials": [
        "local weather/emergency alert source",
        "patient contact list for the day's schedule",
        "staff phone tree or group message list",
        "reporting-time pay policy reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "front-desk",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Owner or designated decision-maker checks local weather/emergency alerts and road/transit status against a fixed cutoff time before the first patient is due (e.g. 90 minutes before open).\n\nWhy: A late decision leaves no time to notify patients or staff before they are already en route.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Check conditions against a fixed decision deadline",
          "why": "A late decision leaves no time to notify patients or staff before they are already en route."
        },
        {
          "detail": "Is it safe and possible to open?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "open",
              "label": "Conditions allow opening, possibly delayed"
            },
            {
              "goto": "s6",
              "id": "close",
              "label": "Close for the day (or delay past a set threshold)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is it safe and possible to open?"
        },
        {
          "detail": "If opening on a delay, office manager notifies staff and any patients scheduled before the new opening time, with the new time confirmed.\n\nWhy: A delay without notification produces a lobby of patients arriving at the original time.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Communicate a delayed-but-open status",
          "why": "A delay without notification produces a lobby of patients arriving at the original time."
        },
        {
          "detail": "Decision time, reason, patients notified count, and pay-policy applied are logged for the day.\n\nRecord: Closure event log: decision time/reason, patient notification status, pay policy applied",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the closure event"
        },
        {
          "detail": "Closure decision process complete",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Closure decision process complete"
        },
        {
          "detail": "Owner records the closure decision, the reason, and the time it was made.\n\nWhy: A time-stamped decision record supports later reporting-time pay determinations and any insurance or lease-related closure claims.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Make the closure decision final and time-stamped",
          "why": "A time-stamped decision record supports later reporting-time pay determinations and any insurance or lease-related closure claims."
        },
        {
          "detail": "Office manager gives front desk the day's schedule and the closure decision so patient outreach can begin immediately.\n\nWhy: Front desk holds the patient contact list and confirmation workflow; the decision-maker should not be the one making the calls.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the closure decision to front desk for patient notification",
          "why": "Front desk holds the patient contact list and confirmation workflow; the decision-maker should not be the one making the calls."
        },
        {
          "detail": "Front desk works the day's schedule top to bottom, contacting each patient by phone, text, or the practice's confirmation system, and offers rebooking.\n\nWhy: Every scheduled patient needs direct notification; a posted sign or voicemail greeting alone is not enough for patients already traveling.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify every scheduled patient",
          "why": "Every scheduled patient needs direct notification; a posted sign or voicemail greeting alone is not enough for patients already traveling."
        },
        {
          "detail": "All scheduled staff are notified via the phone tree or group message, along with how the day will be handled under the practice's reporting-time pay policy.\n\nWhy: Staff who show up unaware of a closure, or who are left unsure about pay, is an avoidable second problem stacked on the closure itself.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify staff of the closure and pay status",
          "why": "Staff who show up unaware of a closure, or who are left unsure about pay, is an avoidable second problem stacked on the closure itself."
        },
        {
          "detail": "The practice owner confirms how reporting-time pay or paid-closure policy applies for this event before it is communicated to staff as final.\n\nWhy: Pay-policy decisions have downstream wage-and-hour consequences and should not be made ad hoc by whoever answers the phone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner confirms the pay-policy application.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner confirms the pay-policy application",
          "why": "Pay-policy decisions have downstream wage-and-hour consequences and should not be made ad hoc by whoever answers the phone."
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "Pre-opening closure decision for weather, outage or emergency (patient notification, reporting-time pay) — Before open, conditions (snow, storm, smoke, outage, transit strike) make opening unsafe or impossible.",
      "title": "Pre-opening closure decision for weather, outage or emergency (patient notification, reporting-time pay)",
      "trigger": "Before open, conditions (snow, storm, smoke, outage, transit strike) make opening unsafe or impossible",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; on-call scheduling does not itself touch controlled-substance security.",
          "source": "DEA 21 CFR 1301.71–1301.76 controlled-substance physical security is this class's regulatory-floor citation, cited only to establish that the class's routines rest on documented regulatory practice; on-call scheduling does not itself touch controlled-substance security.",
          "url": "https://www.ecfr.gov/current/title-21/part-1301"
        },
        {
          "kind": "generic",
          "label": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced"
          },
          "source": "For huddles and meetings: time-boxed agenda, schedule/goal review, medical-alert callouts, action items with owners and dates; no consultancy meeting system is reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "oc-024",
      "kind": "operational",
      "materials": [
        "on-call calendar",
        "reciprocal-coverage agreement (with a peer practice, if one exists)",
        "after-hours answering service or forwarding setup",
        "current dentist contact and license info for the covering provider"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager drafts which dentist is the after-hours contact for each day of the coming month, checking it against known vacations, CE courses, and holidays.\n\nWhy: Building the calendar a month ahead surfaces coverage gaps while there is still time to arrange reciprocal coverage.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the coming month's on-call calendar",
          "why": "Building the calendar a month ahead surfaces coverage gaps while there is still time to arrange reciprocal coverage."
        },
        {
          "detail": "Is a gap found where the only dentist is unreachable?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-gap",
              "label": "A licensed dentist is reachable every day"
            },
            {
              "goto": "s7",
              "id": "gap",
              "label": "A gap exists (solo dentist away, no backup)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a gap found where the only dentist is unreachable?"
        },
        {
          "detail": "Answering service script or phone forwarding is set to route to the correct on-call (or reciprocal) dentist for each stretch of the calendar, and tested.\n\nWhy: An untested forwarding setup is discovered broken exactly when a patient needs it.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Set the after-hours answering/forwarding for each period",
          "why": "An untested forwarding setup is discovered broken exactly when a patient needs it."
        },
        {
          "detail": "The finished on-call calendar, including any reciprocal-coverage dates, is posted where front desk and staff can see who is on call any given day.\n\nWhy: Staff fielding a patient call after hours need to know immediately who to route it to.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Post the on-call calendar for the team",
          "why": "Staff fielding a patient call after hours need to know immediately who to route it to."
        },
        {
          "detail": "The on-call (or covering) dentist takes the after-hours call directly, assesses urgency by phone, and directs the patient to emergency services if the description suggests a medical emergency, or gives interim guidance and a next-business-day appointment otherwise.\n\nWhy: After-hours calls range from reassurance to true emergencies; the on-call dentist is the triage point, not front desk voicemail.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Handle an after-hours call when it comes in",
          "why": "After-hours calls range from reassurance to true emergencies; the on-call dentist is the triage point, not front desk voicemail."
        },
        {
          "detail": "On-call rotation set for the period",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "On-call rotation set for the period"
        },
        {
          "detail": "Dentist contacts the practice(s) holding a standing reciprocal-coverage agreement (or arranges one for the gap dates) and confirms the covering dentist's licensure and contact method for those specific days.\n\nWhy: A gap with no arranged coverage leaves patients with an active dental emergency and no licensed contact.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Arrange reciprocal coverage for the gap",
          "why": "A gap with no arranged coverage leaves patients with an active dental emergency and no licensed contact."
        },
        {
          "detail": "Dentist (or office manager on the dentist's behalf) confirms the covering provider holds an active, unrestricted license for the coverage dates before the calendar shows the gap as closed.\n\nWhy: An unverified covering provider is not a covered gap; a patient in an emergency deserves a confirmed licensed contact, not an assumed one.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the covering dentist's active license before the gap is treated as covered.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm the covering dentist's active license before the gap is treated as covered",
          "why": "An unverified covering provider is not a covered gap; a patient in an emergency deserves a confirmed licensed contact, not an assumed one."
        },
        {
          "detail": "Covering practice, covering dentist, dates covered, and confirmation method logged for the gap period.\n\nRecord: Reciprocal-coverage log: covering practice/dentist, dates, confirmation",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the reciprocal-coverage arrangement"
        }
      ],
      "subclass": "operating-rhythm-opening-closing-and-meetings",
      "summary": "After-hours on-call rotation and reciprocal-coverage agreement with another practice — The on-call calendar is built monthly, or the only dentist will be unreachable over a holiday.",
      "title": "After-hours on-call rotation and reciprocal-coverage agreement with another practice",
      "trigger": "The on-call calendar is built monthly, or the only dentist will be unreachable over a holiday",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(c) — Exposure Control Plan and annual review",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(c) — Exposure Control Plan and annual review",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Bloodborne Pathogens Title 8 §5193",
          "source": "Cal/OSHA Bloodborne Pathogens Title 8 §5193",
          "url": "https://www.dir.ca.gov/title8/5193.html"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "osha-001",
      "kind": "compliance",
      "materials": [
        "Written Exposure Control Plan document",
        "Task/procedure exposure classification list",
        "Safer medical device evaluation log",
        "Sharps injury log (prior 12 months)",
        "Staff training records"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "dentist",
        "practice-owner",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the trigger: the plan's annual anniversary date has arrived, a new task with anticipated blood/OPIM exposure was added, or a safer-device evaluation is due.\n\nWhy: Keeps the review cycle tied to a real trigger instead of drifting off schedule.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the review trigger",
          "why": "Keeps the review cycle tied to a real trigger instead of drifting off schedule."
        },
        {
          "detail": "Retrieve the current signed Exposure Control Plan and the task/procedure exposure classification list from the compliance record system.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the current written plan"
        },
        {
          "detail": "Walk each section: exposure determination list, methods of compliance, PPE, HBV vaccination offer, post-exposure evaluation procedure, hazard communication, recordkeeping.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review core plan sections"
        },
        {
          "detail": "Compare the current exposure-classification list against actual job duties for every role; add or reclassify any task that now involves reasonably anticipated blood/OPIM exposure.\n\nWhy: New procedures or delegated duties change who is occupationally exposed under the standard.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Reconcile the task list against current duties",
          "why": "New procedures or delegated duties change who is occupationally exposed under the standard."
        },
        {
          "detail": "Document consideration of currently available engineering controls, such as safety-engineered sharps and needleless systems, and record which were adopted and why.\n\nWhy: The standard requires documented annual input into safer-device selection from non-managerial exposed employees.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review safer medical device options",
          "why": "The standard requires documented annual input into safer-device selection from non-managerial exposed employees."
        },
        {
          "detail": "Ask non-managerial employees who use sharps for their input on identifying, evaluating and selecting safer devices; record who was asked and when.",
          "id": "s6",
          "kind": "step",
          "role": "all-staff",
          "title": "Solicit non-managerial staff input"
        },
        {
          "detail": "Does the plan need substantive changes?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes-update",
              "label": "Yes — update the written plan"
            },
            {
              "goto": "s13",
              "id": "no-change",
              "label": "No — plan remains current, log the review only"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the plan need substantive changes?"
        },
        {
          "detail": "Edit the written plan with the identified changes and route the draft to the dentist and practice owner for review before finalizing.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft and route plan updates"
        },
        {
          "detail": "Compliance officer certifies the updated or reaffirmed plan is complete and dates the document before distribution.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on the plan.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on the plan"
        },
        {
          "detail": "Hand the finalized plan to office-manager to schedule refresher training on any changed sections within 30 days.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Distribute and schedule refresher training"
        },
        {
          "detail": "Store the signed plan and review log in the compliance record system with the next anniversary date calendared.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File signed plan and calendar next review"
        },
        {
          "detail": "Exposure Control Plan review complete",
          "id": "s12",
          "kind": "step",
          "title": "Exposure Control Plan review complete"
        },
        {
          "detail": "Record the review date, reviewer, and the finding that no substantive change was needed in the compliance log.",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the no-change annual review"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Exposure Control Plan annual review and update — The plan anniversary date arrives, a new task with blood exposure is introduced, or a safer-device evaluation is due.",
      "title": "Exposure Control Plan annual review and update",
      "trigger": "The plan anniversary date arrives, a new task with blood exposure is introduced, or a safer-device evaluation is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(g)(2) — training program elements and interactive requirement",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(g)(2) — training program elements and interactive requirement",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Bloodborne Pathogens Title 8 §5193 training requirements",
          "source": "Cal/OSHA Bloodborne Pathogens Title 8 §5193 training requirements",
          "url": "https://www.dir.ca.gov/title8/5193.html"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "osha-002",
      "kind": "compliance",
      "materials": [
        "Bloodborne pathogens training curriculum covering exposure control, transmission, PPE, HBV vaccine, exposure procedures",
        "Copy of the current Exposure Control Plan",
        "Sign-in / completion roster",
        "Post-training comprehension quiz"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "HR flags any new hire with reasonably anticipated occupational exposure, or any current employee approaching 12 months since their last training.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Identify who needs training"
        },
        {
          "detail": "Confirm the curriculum covers the required elements: exposure control plan, epidemiology, transmission modes, PPE use, HBV vaccine, exposure procedures, and signage/labeling/color coding.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Assemble training content"
        },
        {
          "detail": "Schedule the session before the new hire performs any task with exposure risk, or within 12 months of the employee's prior session.",
          "id": "s3",
          "kind": "step",
          "role": "hr",
          "title": "Schedule the training session"
        },
        {
          "detail": "Present the material and give trainees a real opportunity to ask questions and interact with a knowledgeable person, not just watch a passive video.\n\nWhy: The standard requires an interactive opportunity for questions, not one-way viewing.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Deliver interactive training",
          "why": "The standard requires an interactive opportunity for questions, not one-way viewing."
        },
        {
          "detail": "Give a short comprehension quiz covering transmission routes, PPE use, and post-exposure steps; review any missed items with the trainee.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Administer the post-training quiz"
        },
        {
          "detail": "Did the trainee demonstrate understanding?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "passed",
              "label": "Yes — sign off on completion"
            },
            {
              "goto": "s11",
              "id": "failed",
              "label": "No — re-teach the missed sections"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did the trainee demonstrate understanding?"
        },
        {
          "detail": "Compliance officer confirms the roster entry, quiz result, and training date are complete before the record is filed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on completion.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on completion"
        },
        {
          "detail": "File the signed roster, quiz result, and topics covered in the employee's training file for inspection readiness.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "File the training record"
        },
        {
          "detail": "Hand off confirmation to office-manager so the employee can be scheduled for exposure-risk tasks.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Notify office-manager of completion"
        },
        {
          "detail": "Bloodborne pathogens training documented",
          "id": "s10",
          "kind": "step",
          "title": "Bloodborne pathogens training documented"
        },
        {
          "detail": "Re-cover the specific quiz sections the trainee missed one-on-one before re-administering that portion of the quiz.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Re-teach missed sections"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Bloodborne pathogens training (hire and annual) — A new employee with occupational exposure starts, or 12 months have elapsed since a staff member's last training.",
      "title": "Bloodborne pathogens training (hire and annual)",
      "trigger": "A new employee with occupational exposure starts, or 12 months have elapsed since a staff member's last training",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(f)(1) — Hepatitis B vaccination offer within 10 working days, and declination statement",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(f)(1) — Hepatitis B vaccination offer within 10 working days, and declination statement",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "public_domain",
          "label": "CDC ACIP Hepatitis B vaccination schedule guidance (public domain)",
          "source": "CDC ACIP Hepatitis B vaccination schedule guidance (public domain)",
          "url": "https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "once",
      "id": "osha-003",
      "kind": "compliance",
      "materials": [
        "Hepatitis B vaccine offer form",
        "CDC/ACIP vaccination schedule information sheet",
        "Declination statement covering the offer, the risk, and the right to vaccinate later",
        "Vaccination provider/clinic contact information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "compliance-officer",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "HR flags any new hire whose job duties include reasonably anticipated occupational exposure to blood or OPIM.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Identify the eligible employee"
        },
        {
          "detail": "Offer the Hepatitis B vaccination series at no cost to the employee, following the CDC ACIP schedule, within ten working days of the start of duties with exposure risk.\n\nWhy: The standard sets a ten-working-day offer window from the start of occupational exposure.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Present the vaccine offer",
          "why": "The standard sets a ten-working-day offer window from the start of occupational exposure."
        },
        {
          "detail": "The employee decides in writing whether to accept or decline the vaccination series; the decision is documented either way, without coercion.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Employee consent decision.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "all-staff",
          "title": "Employee consent decision"
        },
        {
          "detail": "Accept or decline?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accept",
              "label": "Employee accepts the vaccination series"
            },
            {
              "goto": "s9",
              "id": "decline",
              "label": "Employee declines"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Accept or decline?"
        },
        {
          "detail": "Hand off to the vaccination provider/clinic to begin the series following the ACIP schedule; HR tracks completion of each dose.",
          "id": "s5",
          "kind": "step",
          "role": "hr",
          "title": "Schedule the vaccination series"
        },
        {
          "detail": "File the dated vaccination record, or the in-progress series status, in the employee's confidential medical file.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "File the vaccination record"
        },
        {
          "detail": "Remind employees who declined, in writing, that they may request the vaccine at any later date at no cost if they change their mind.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the continued right to vaccinate"
        },
        {
          "detail": "Hepatitis B offer and record complete",
          "id": "s8",
          "kind": "step",
          "title": "Hepatitis B offer and record complete"
        },
        {
          "detail": "Have the employee sign a declination statement acknowledging the offer, the exposure risk, and the right to vaccinate later at no cost.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Obtain a signed declination statement"
        },
        {
          "detail": "File the signed declination in the confidential medical file; note that it does not expire and can be revisited at any time.",
          "id": "s10",
          "kind": "step",
          "role": "hr",
          "title": "File the declination statement"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Hepatitis B vaccination offer, titer and declination record within ten working days — A new hire with occupational exposure risk starts, or an employee who previously declined asks to be vaccinated.",
      "title": "Hepatitis B vaccination offer, titer and declination record within ten working days",
      "trigger": "A new hire with occupational exposure risk starts, or an employee who previously declined asks to be vaccinated",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(f)(3) — post-exposure evaluation and follow-up, confidential medical evaluation at no cost",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(f)(3) — post-exposure evaluation and follow-up, confidential medical evaluation at no cost",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "public_domain",
          "label": "CDC/USPHS post-exposure prophylaxis guidelines for HIV, HBV, HCV (public domain)",
          "source": "CDC/USPHS post-exposure prophylaxis guidelines for HIV, HBV, HCV (public domain)",
          "url": "https://www.cdc.gov/mmwr/volumes/65/rr/rr6509a1.htm"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "osha-004",
      "kind": "compliance",
      "materials": [
        "Handwashing / first-aid station",
        "First aid supplies",
        "Sharps injury log",
        "Source patient testing consent form, where applicable",
        "Designated post-exposure evaluation clinic contact information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "office-manager",
        "compliance-officer",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Immediately wash the puncture or cut site with soap and water, or flush affected mucous membranes with water or saline; do not squeeze or aggressively scrub the wound.\n\nWhy: Immediate washing reduces bioburden at the exposure site per CDC guidance.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Provide immediate first aid",
          "why": "Immediate washing reduces bioburden at the exposure site per CDC guidance."
        },
        {
          "detail": "Tell the treating dentist or office-manager on duty right away so the procedure can be safely paused and the incident logged.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Report to the supervisor immediately"
        },
        {
          "detail": "Route the employee to the designated post-exposure evaluation clinician within two hours; evaluation must be confidential and at no cost to the employee.\n\nWhy: The standard requires immediate access to confidential post-exposure medical evaluation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route to confidential post-exposure evaluation.",
            "role": "occupational health evaluating clinician",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Route to confidential post-exposure evaluation",
          "why": "The standard requires immediate access to confidential post-exposure medical evaluation."
        },
        {
          "detail": "Is a source patient identifiable?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "known",
              "label": "Source patient identifiable"
            },
            {
              "goto": "s12",
              "id": "unknown",
              "label": "Source unknown or unavailable"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is a source patient identifiable?"
        },
        {
          "detail": "With the source patient's informed consent, or per the applicable legal basis where consent cannot be obtained, arrange testing for HBV, HCV and HIV status and document the consent or legal basis.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain source patient consent for testing.",
            "type": "safety"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Obtain source patient consent for testing"
        },
        {
          "detail": "Provide the source patient's test results, when available, directly to the evaluating clinician handling the exposed employee's care, not to coworkers.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Share source results with the evaluating clinician"
        },
        {
          "detail": "The licensed evaluating clinician determines exposure severity and whether HIV/HBV/HCV post-exposure prophylaxis is indicated, following CDC/USPHS guidelines.\n\nWhy: Only a licensed clinician makes the treatment call; this protocol only routes and documents the process.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Clinician assesses exposure and post-exposure prophylaxis",
          "why": "Only a licensed clinician makes the treatment call; this protocol only routes and documents the process."
        },
        {
          "detail": "The employer receives only the clinician's limited written opinion — whether HBV vaccination was recommended and that the employee was informed of results — not full medical details.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Receive the clinician's written opinion"
        },
        {
          "detail": "Hand off exposure details to compliance-officer to enter on the OSHA 300 log, if recordable, and on the sharps injury log.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Log the incident"
        },
        {
          "detail": "Review the circumstances — device type, procedure step, safer-device availability — to identify a prevention opportunity for the next annual device review.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Conduct a prevention review"
        },
        {
          "detail": "Needlestick or sharps injury response complete",
          "id": "s11",
          "kind": "step",
          "title": "Needlestick or sharps injury response complete"
        },
        {
          "detail": "Record that the source patient could not be identified or tested; the evaluating clinician determines the appropriate course from CDC/USPHS guidance without source data.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document source status as unknown"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Needlestick or contaminated sharps injury — first aid, source evaluation, post-exposure evaluation within two hours — A team member is stuck by a used needle, bur, scaler or explorer, or cut by a contaminated instrument.",
      "title": "Needlestick or contaminated sharps injury — first aid, source evaluation, post-exposure evaluation within two hours",
      "trigger": "A team member is stuck by a used needle, bur, scaler or explorer, or cut by a contaminated instrument",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(f)(3) — post-exposure evaluation and follow-up applies to mucous membrane and non-intact skin exposures",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(f)(3) — post-exposure evaluation and follow-up applies to mucous membrane and non-intact skin exposures",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "regulation",
          "label": "OSHA Eyewash and shower requirement, 29 CFR 1910.151(c)",
          "source": "OSHA Eyewash and shower requirement, 29 CFR 1910.151(c)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.151"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osha-005",
      "kind": "compliance",
      "materials": [
        "Eyewash station",
        "Handwashing station",
        "Designated post-exposure evaluation clinic contact information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pause the procedure at a safe point, remove gloves, mask and eyewear without further contaminating skin, and hand the patient off to another available staff member to monitor while you go flush at the eyewash station.",
          "id": "s1",
          "kind": "step",
          "role": "all-staff",
          "title": "Stop the procedure safely and remove contaminated PPE"
        },
        {
          "detail": "Flush eyes at the eyewash station for at least 15 minutes, or rinse the mouth or mucous membranes and wash exposed skin with soap and water right away.\n\nWhy: Eyewash and shower requirements call for immediate flushing capability for biological exposures.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Flush the exposed area immediately",
          "why": "Eyewash and shower requirements call for immediate flushing capability for biological exposures."
        },
        {
          "detail": "Notify the treating dentist or office-manager on duty so the exposure can be logged and evaluation arranged.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Report to the supervisor immediately"
        },
        {
          "detail": "Route the exposed employee to confidential post-exposure medical evaluation promptly, following the same evaluation pathway used for a sharps injury.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route to confidential post-exposure evaluation.",
            "role": "occupational health evaluating clinician",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Route to confidential post-exposure evaluation"
        },
        {
          "detail": "Is the source patient identifiable and available?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "known",
              "label": "Yes"
            },
            {
              "goto": "s10",
              "id": "unknown",
              "label": "No"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the source patient identifiable and available?"
        },
        {
          "detail": "With the source patient's informed consent, arrange source testing and forward the results directly to the evaluating clinician.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Request source testing with consent"
        },
        {
          "detail": "Record the incident with route of exposure, body fluid, and body site affected; note that it counts toward the OSHA recordability review.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the exposure"
        },
        {
          "detail": "Review whether better eye protection, isolation, or a change in technique would have prevented the splash, and note it for the next PPE hazard assessment.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Conduct a prevention review"
        },
        {
          "detail": "Splash exposure response complete",
          "id": "s9",
          "kind": "step",
          "title": "Splash exposure response complete"
        },
        {
          "detail": "Record that source testing was not possible; the evaluating clinician proceeds per CDC/USPHS guidance without it.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document source unavailable"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Blood or saliva splash to eyes, mouth or non-intact skin — Spray or spatter reaches a staff member's eyes, mouth or a cut on the hands during a procedure or instrument processing.",
      "title": "Blood or saliva splash to eyes, mouth or non-intact skin",
      "trigger": "Spray or spatter reaches a staff member's eyes, mouth or a cut on the hands during a procedure or instrument processing",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(h)(5) — sharps injury log requirement",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(h)(5) — sharps injury log requirement",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(c)(1)(iv) — annual safer-device review with frontline employee input",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(c)(1)(iv) — annual safer-device review with frontline employee input",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osha-006",
      "kind": "compliance",
      "materials": [
        "Sharps injury log, confidential recordkeeping format",
        "Device evaluation forms",
        "Product literature for safer sharps devices"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm a percutaneous sharps injury was just reported, or the annual safer-device review date has arrived.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the trigger"
        },
        {
          "detail": "Log a new injury, or run the annual review?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "log-new",
              "label": "New sharps injury to log"
            },
            {
              "goto": "s7",
              "id": "annual",
              "label": "Annual safer-device review"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Log a new injury, or run the annual review?"
        },
        {
          "detail": "Record the device type and brand, work area, and how the injury occurred, keeping the log confidential and without unnecessary personal identifiers.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Enter the injury in the sharps injury log"
        },
        {
          "detail": "Determine whether the injury also meets OSHA 300 recordability criteria and enter it there if so.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Cross-check with the OSHA 300 log"
        },
        {
          "detail": "Add this injury's device and procedure context to the running file used for the next annual safer-device evaluation.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Feed the entry into the next device review"
        },
        {
          "detail": "Sharps injury log and device review complete",
          "id": "s6",
          "kind": "step",
          "title": "Sharps injury log and device review complete"
        },
        {
          "detail": "Pull every log entry from the past 12 months and summarize by device type and procedure.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compile the year's sharps injury log"
        },
        {
          "detail": "Review currently used sharps devices against available engineering-control alternatives, such as retractable, blunt or safety-engineered options, for each high-injury device type.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Evaluate current and alternative safer devices"
        },
        {
          "detail": "Ask non-managerial staff who use the devices for their input before finalizing which alternatives to adopt.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Solicit frontline input on device choices"
        },
        {
          "detail": "Compliance officer signs off on which devices are adopted, deferred, or rejected, with reasons documented for each.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on device decisions.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on device decisions"
        },
        {
          "detail": "File the device review outcome and cross-reference the update in the Exposure Control Plan for next year's cycle.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the annual review outcome"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Sharps injury log entry and annual safer-device review — Any percutaneous injury from a contaminated sharp is reported, or the annual safer-device evaluation is due.",
      "title": "Sharps injury log entry and annual safer-device review",
      "trigger": "Any percutaneous injury from a contaminated sharp is reported, or the annual safer-device evaluation is due",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication standard 29 CFR 1910.1200 — written program, SDS access, container labeling",
          "source": "OSHA Hazard Communication standard 29 CFR 1910.1200 — written program, SDS access, container labeling",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Hazard Communication Title 8 §5194",
          "source": "Cal/OSHA Hazard Communication Title 8 §5194",
          "url": "https://www.dir.ca.gov/title8/5194.html"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "annual",
      "id": "osha-007",
      "kind": "compliance",
      "materials": [
        "Chemical inventory list",
        "Safety Data Sheet binder or digital SDS system",
        "Secondary container labels",
        "Written Hazard Communication program document"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "sterilization-tech",
        "assistant",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm a new chemical product was received, an SDS is missing when requested, or the annual reconciliation date has arrived.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the chemical inventory trigger"
        },
        {
          "detail": "Walk the operatories, sterilization area, and storage rooms; list every hazardous chemical product present, matching brand and formulation.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Reconcile the chemical inventory list"
        },
        {
          "detail": "Is an SDS on file for every listed chemical?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "complete",
              "label": "Yes — proceed to labeling check"
            },
            {
              "goto": "s10",
              "id": "missing",
              "label": "No — a missing SDS was found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is an SDS on file for every listed chemical?"
        },
        {
          "detail": "Confirm every secondary container, such as spray bottles and dispensing containers, is labeled with the product identity and hazard warning, not just the original manufacturer container.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Check secondary container labeling"
        },
        {
          "detail": "Revise the written program to reflect any new hazard classes, labeling changes, or SDS system changes.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the written hazard communication program"
        },
        {
          "detail": "Compliance officer signs off that the inventory, SDS binder, and labeling are current before closing the review.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on the program.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on the program"
        },
        {
          "detail": "Hand off to office-manager to brief staff on any newly added hazardous chemicals at the next staff meeting.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief staff on new hazards"
        },
        {
          "detail": "File the dated inventory reconciliation and SDS completeness confirmation in the compliance record system.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the reconciliation record"
        },
        {
          "detail": "Hazard communication program current",
          "id": "s9",
          "kind": "step",
          "title": "Hazard communication program current"
        },
        {
          "detail": "Request the current Safety Data Sheet from the manufacturer or distributor and add it to the SDS binder or digital system before the chemical is used again.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Obtain the missing SDS"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Hazard communication program — chemical inventory, SDS binder and labeling — A new chemical product is received, an SDS is missing when requested, or the annual inventory reconciliation is due.",
      "title": "Hazard communication program — chemical inventory, SDS binder and labeling",
      "trigger": "A new chemical product is received, an SDS is missing when requested, or the annual inventory reconciliation is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Personal Protective Equipment standard 29 CFR 1910.132(d) — written hazard assessment and certification",
          "source": "OSHA Personal Protective Equipment standard 29 CFR 1910.132(d) — written hazard assessment and certification",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.132"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(d)(3) — PPE provision specific to blood/OPIM exposure",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030(d)(3) — PPE provision specific to blood/OPIM exposure",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "annual",
      "id": "osha-008",
      "kind": "compliance",
      "materials": [
        "Written PPE hazard assessment form",
        "PPE inventory: masks, gloves, protective eyewear or face shields, gowns",
        "Task-to-PPE assignment matrix"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm a new procedure or role was added, PPE stock is running short, or the annual written hazard-assessment certification is due.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the assessment trigger"
        },
        {
          "detail": "For each role — dentist, hygienist, assistant, sterilization-tech — identify splash, spatter, aerosol, and sharps hazards specific to their tasks.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Walk through each task and role for hazard exposure"
        },
        {
          "detail": "Assign required PPE per task: gloves, mask or respirator level, eye protection or face shield, and protective clothing, following the exposure determination list.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Match PPE to identified hazards"
        },
        {
          "detail": "Does current PPE stock meet what's needed?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "sufficient",
              "label": "Yes — stock is sufficient"
            },
            {
              "goto": "s10",
              "id": "short",
              "label": "No — a shortage was identified"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does current PPE stock meet what's needed?"
        },
        {
          "detail": "Confirm PPE sizing and fit works for each staff member using it, especially gloves and eye protection, and swap sizes as needed.",
          "id": "s5",
          "kind": "step",
          "role": "all-staff",
          "title": "Fit and comfort check with staff"
        },
        {
          "detail": "Compliance officer signs and dates the written PPE hazard assessment certification, as the standard requires.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on the hazard assessment.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on the hazard assessment"
        },
        {
          "detail": "File the signed hazard assessment certification and the updated task-to-PPE matrix in the compliance record system.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the certification"
        },
        {
          "detail": "Hand off the updated task-to-PPE matrix to office-manager to post at relevant stations and cover in the next staff meeting.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Communicate assignments to staff"
        },
        {
          "detail": "PPE hazard assessment complete",
          "id": "s9",
          "kind": "step",
          "title": "PPE hazard assessment complete"
        },
        {
          "detail": "Place an order for the missing sizes or types, or arrange a temporary substitute that still meets the hazard assessment, until stock arrives.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Reorder or substitute PPE"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "PPE hazard assessment, provision and replacement — A new procedure or role is added, PPE stock runs short, or the annual written hazard-assessment certification is due.",
      "title": "PPE hazard assessment, provision and replacement",
      "trigger": "A new procedure or role is added, PPE stock runs short, or the annual written hazard-assessment certification is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Respiratory Protection 29 CFR 1910.134",
          "source": "OSHA Respiratory Protection 29 CFR 1910.134",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.134"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "annual",
      "id": "osha-009",
      "kind": "compliance",
      "materials": [
        "respirator medical questionnaire",
        "fit-test kit (qualitative or quantitative)",
        "respirator models in stock sizes",
        "written respiratory protection program document",
        "training log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "hygienist",
        "assistant",
        "dentist",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "List every role performing or assisting aerosol-generating procedures (drilling, ultrasonic scaling, high-speed handpiece use) who will wear an N95 or better.\n\nWhy: 29 CFR 1910.134 requires a written program covering everyone assigned to wear a respirator, not just those who ask for one.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify staff who need respiratory protection",
          "why": "29 CFR 1910.134 requires a written program covering everyone assigned to wear a respirator, not just those who ask for one."
        },
        {
          "detail": "Give each affected staff member the OSHA respirator medical evaluation questionnaire (Appendix C) confidentially, before any fit test.\n\nWhy: A physician or licensed healthcare professional must clear the wearer medically before a fit test proceeds.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Administer medical evaluation questionnaire",
          "why": "A physician or licensed healthcare professional must clear the wearer medically before a fit test proceeds."
        },
        {
          "detail": "PLHCP determines the staff member is cleared, cleared with restriction, or needs further evaluation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Physician/licensed healthcare professional (PLHCP) reviews the questionnaire.",
            "role": "physician/licensed healthcare professional (PLHCP)",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Physician/licensed healthcare professional (PLHCP) reviews the questionnaire"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Respiratory protection program — medical clearance, N95 fit test and training — A staff member will wear a respirator for aerosol-generating procedures, 12 months have passed since the last fit test, or a facial change or new model requires a refit.",
      "title": "Respiratory protection program — medical clearance, N95 fit test and training",
      "trigger": "A staff member will wear a respirator for aerosol-generating procedures, 12 months have passed since the last fit test, or a facial change or new model requires a refit",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA IIPP Title 8 §3203; Bloodborne Pathogens §5193; Aerosol Transmissible Diseases §5199; Workplace Violence Prevention Labor Code §6401.9",
          "source": "Cal/OSHA IIPP Title 8 §3203; Bloodborne Pathogens §5193; Aerosol Transmissible Diseases §5199; Workplace Violence Prevention Labor Code §6401.9",
          "url": "https://www.dir.ca.gov/title8/3203.html"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osha-010",
      "kind": "compliance",
      "materials": [
        "eyewash station",
        "safety data sheet (SDS) binder",
        "first aid kit",
        "incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "compliance-officer",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "If the person has difficulty breathing, a significant chemical burn, altered consciousness, or ingested a chemical, call 911 immediately before anything else.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Assess severity — call 911 if breathing trouble, chemical burn or loss of consciousness.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Assess severity — call 911 if breathing trouble, chemical burn or loss of consciousness"
        },
        {
          "detail": "Is this an eye/skin contact or an inhalation/fume exposure?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "contact",
              "label": "Eye or skin contact"
            },
            {
              "goto": "s9",
              "id": "inhalation",
              "label": "Inhalation / overcome by fumes"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Is this an eye/skin contact or an inhalation/fume exposure?"
        },
        {
          "detail": "Use the eyewash station for eye contact (hold eyelids open, roll eyes) or flush skin with copious water; remove contaminated clothing or jewelry.\n\nWhy: 29 CFR 1910.151(c) requires immediate flushing access; most chemical eye injuries worsen if flushing is delayed or too brief.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Flush the affected area at the eyewash or sink for at least 15 minutes",
          "why": "29 CFR 1910.151(c) requires immediate flushing access; most chemical eye injuries worsen if flushing is delayed or too brief."
        },
        {
          "detail": "Locate the SDS in the hazard communication binder for the specific product and read the first-aid and exposure sections aloud.\n\nWhy: The SDS gives chemical-specific first-aid guidance (e.g. antidotes, contraindications) that generic flushing does not cover.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the Safety Data Sheet for the chemical involved",
          "why": "The SDS gives chemical-specific first-aid guidance (e.g. antidotes, contraindications) that generic flushing does not cover."
        },
        {
          "detail": "Does the SDS or symptom severity call for professional medical evaluation?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "seek-care",
              "label": "Send for urgent care or ER evaluation"
            },
            {
              "goto": "s7",
              "id": "monitor",
              "label": "Symptoms resolved with flushing — monitor and document"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Does the SDS or symptom severity call for professional medical evaluation?"
        },
        {
          "detail": "Send the affected staff member to urgent care or the ER with a printed copy of the SDS for the chemical involved.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange transport and hand off SDS copy to the treating clinician"
        },
        {
          "detail": "Record the chemical, exposure route, first aid given, and outcome in the incident log; evaluate whether OSHA 300 recording criteria are met.\n\nRecord: chemical exposure incident report — chemical name, route, first aid, outcome",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the exposure incident"
        },
        {
          "detail": "Exposure treated and documented",
          "id": "s8",
          "kind": "step",
          "title": "Exposure treated and documented"
        },
        {
          "detail": "Evacuate the person from the fume source to outdoor or fresh-air space; loosen tight clothing and monitor for worsening symptoms.",
          "id": "s9",
          "kind": "step",
          "role": "all-staff",
          "title": "Move the person to fresh air and monitor breathing"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Chemical splash, eye contact or inhalation (disinfectant, sterilant, etchant, monomer) — A staff member gets a chemical in the eyes or on the skin, or is overcome by fumes in the sterilization area.",
      "title": "Chemical splash, eye contact or inhalation (disinfectant, sterilant, etchant, monomer)",
      "trigger": "A staff member gets a chemical in the eyes or on the skin, or is overcome by fumes in the sterilization area",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "source": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "url": "https://www.ecfr.gov/current/title-29/part-1904"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osha-011",
      "kind": "compliance",
      "materials": [
        "OSHA Form 300 (log)",
        "OSHA Form 301 (incident report)",
        "OSHA Form 300A (summary)",
        "prior-year injury records"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "What triggered this task?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "injury",
              "label": "A work-related injury or illness occurred"
            },
            {
              "goto": "s6",
              "id": "annual",
              "label": "It is the annual February–April posting window"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "title": "What triggered this task?"
        },
        {
          "detail": "Does the injury meet OSHA recordability criteria?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "recordable",
              "label": "Beyond first aid, lost time, restricted duty, or medical treatment"
            },
            {
              "goto": "s7",
              "id": "first-aid-only",
              "label": "First aid only — not recordable"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Does the injury meet OSHA recordability criteria?"
        },
        {
          "detail": "Add a line to Form 300 with case classification (days away, restricted, other recordable), body part, and cause.\n\nWhy: 29 CFR 1904.29 sets a 7-calendar-day deadline from when the employer learns of a recordable case.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Enter the injury on the OSHA 300 log within 7 calendar days",
          "why": "29 CFR 1904.29 sets a 7-calendar-day deadline from when the employer learns of a recordable case."
        },
        {
          "detail": "Fill out Form 301 (or an equivalent) with how the injury occurred, what the employee was doing, and treatment given, within the same 7-day window.\n\nRecord: OSHA Form 301 incident report on file",
          "id": "s4",
          "kind": "step",
          "role": "hr",
          "title": "Complete the OSHA 301 incident report"
        },
        {
          "detail": "Recordkeeping obligation satisfied",
          "id": "s5",
          "kind": "step",
          "title": "Recordkeeping obligation satisfied"
        },
        {
          "detail": "Total the prior calendar year's 300 log, have a company executive certify Form 300A, and post it in a visible employee area from February 1 through April 30.\n\nWhy: 29 CFR 1904.32 requires the summary posted where employees can see it, even in years with zero recordable injuries.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare and post the annual OSHA 300A summary",
          "why": "29 CFR 1904.32 requires the summary posted where employees can see it, even in years with zero recordable injuries."
        },
        {
          "detail": "Record the minor incident in the office first-aid log for internal tracking even though it is not OSHA-recordable.\n\nRecord: internal first-aid log entry",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Note first-aid-only treatment informally"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "OSHA 300 log entry, 301 report and annual 300A posting — A work-related injury needs treatment beyond first aid, results in lost time or hospitalization, or it is February 1 (post the prior-year summary through April 30).",
      "title": "OSHA 300 log entry, 301 report and annual 300A posting",
      "trigger": "A work-related injury needs treatment beyond first aid, results in lost time or hospitalization, or it is February 1 (post the prior-year summary through April 30)",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "source": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "url": "https://www.ecfr.gov/current/title-29/part-1904"
        },
        {
          "kind": "regulation",
          "label": "OSHA severe injury reporting requirement 29 CFR 1904.39",
          "source": "OSHA severe injury reporting requirement 29 CFR 1904.39",
          "url": "https://www.ecfr.gov/current/title-29/section-1904.39"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "osha-012",
      "kind": "compliance",
      "materials": [
        "OSHA 300/301 forms",
        "incident timeline notes",
        "OSHA regional office contact number"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "ems",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If the employee needs emergency medical care right now, call 911 before any reporting steps begin.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 first if there is an active medical emergency.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 first if there is an active medical emergency"
        },
        {
          "detail": "What is the severity of the outcome?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "fatality",
              "label": "Employee fatality"
            },
            {
              "goto": "s8",
              "id": "hospitalized",
              "label": "In-patient hospitalization, amputation, or loss of an eye"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "What is the severity of the outcome?"
        },
        {
          "detail": "The practice owner or designated compliance officer confirms the facts and authorizes the required call to OSHA within 8 hours of the fatality.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews and authorizes the OSHA report.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews and authorizes the OSHA report"
        },
        {
          "detail": "Call the nearest OSHA area office, or the 24-hour OSHA hotline, or use the online severe injury report form; give the employer name, location, time, and nature of the event.\n\nWhy: 29 CFR 1904.39 sets fixed deadlines (8 hours for a fatality, 24 hours for in-patient hospitalization/amputation/eye loss) that do not wait for a full investigation.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Report to OSHA by phone or the online severe injury reporting form",
          "why": "29 CFR 1904.39 sets fixed deadlines (8 hours for a fatality, 24 hours for in-patient hospitalization/amputation/eye loss) that do not wait for a full investigation."
        },
        {
          "detail": "Document what happened, when, who was involved, and immediate corrective actions taken, separate from any 300/301 log entries.\n\nRecord: written incident timeline, event report reference number from OSHA",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Write a factual timeline of the event"
        },
        {
          "detail": "Route this incident into the standard OSHA 300 log entry and 301 incident report protocol to complete recordkeeping.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the OSHA 300 log/301 report process"
        },
        {
          "detail": "Severe injury reported to OSHA within the statutory deadline",
          "id": "s7",
          "kind": "step",
          "title": "Severe injury reported to OSHA within the statutory deadline"
        },
        {
          "detail": "The practice owner or designated compliance officer confirms the facts and authorizes the required call to OSHA within 24 hours of the hospitalization, amputation, or eye loss.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews and authorizes the OSHA report.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews and authorizes the OSHA report"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Reporting a work-related fatality, hospitalization, amputation or eye loss to OSHA — An employee is hospitalized in-patient (report within 24 hours) or dies (report within 8 hours) from a workplace event.",
      "title": "Reporting a work-related fatality, hospitalization, amputation or eye loss to OSHA",
      "trigger": "An employee is hospitalized in-patient (report within 24 hours) or dies (report within 8 hours) from a workplace event",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "source": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "url": "https://www.ecfr.gov/current/title-29/part-1904"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "annual",
      "id": "osha-013",
      "kind": "compliance",
      "materials": [
        "written emergency action plan",
        "written fire prevention plan",
        "floor plan with exits and assembly point marked",
        "fire extinguisher inspection tags"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Retrieve both written plans and the marked floor plan showing exits, extinguisher locations, and the outdoor assembly point.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the current written emergency action and fire prevention plans"
        },
        {
          "detail": "Confirm every exit is unobstructed and marked, extinguishers are in place and tagged current, and the floor plan matches any renovations since the last review.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Walk the office and verify the plan still matches reality"
        },
        {
          "detail": "Did the walkthrough find a mismatch between the plan and the office?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-gap",
              "label": "Plan matches the office — no changes needed"
            },
            {
              "goto": "s7",
              "id": "gap-found",
              "label": "Layout, exits, or roles have changed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "title": "Did the walkthrough find a mismatch between the plan and the office?"
        },
        {
          "detail": "Walk every staff member — including any new hires since the last review — through the evacuation routes and their assigned role during an emergency.\n\nWhy: 1910.38 requires employees know their role and route before an actual emergency, not during one.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Orient all staff to the current plan",
          "why": "1910.38 requires employees know their role and route before an actual emergency, not during one."
        },
        {
          "detail": "Record the review date, who attended orientation, and any plan updates made in the compliance binder.\n\nRecord: annual emergency action plan review log — date, attendees, changes made",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the review date and attendees"
        },
        {
          "detail": "Emergency action and fire prevention plans current and staff oriented",
          "id": "s6",
          "kind": "step",
          "title": "Emergency action and fire prevention plans current and staff oriented"
        },
        {
          "detail": "Revise the evacuation routes, assembly point, or role assignments (who accounts for staff, who calls 911) to match the current office.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the written plan and floor diagram"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Emergency action plan and fire prevention plan written review — The annual review date arrives, the floor plan changes, or a new hire needs evacuation orientation.",
      "title": "Emergency action plan and fire prevention plan written review",
      "trigger": "The annual review date arrives, the floor plan changes, or a new hire needs evacuation orientation",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA IIPP Title 8 §3203; Bloodborne Pathogens §5193; Aerosol Transmissible Diseases §5199; Workplace Violence Prevention Labor Code §6401.9",
          "source": "Cal/OSHA IIPP Title 8 §3203; Bloodborne Pathogens §5193; Aerosol Transmissible Diseases §5199; Workplace Violence Prevention Labor Code §6401.9",
          "url": "https://www.dir.ca.gov/title8/3203.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "source": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "url": "https://www.ecfr.gov/current/title-29/part-1904"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "osha-014",
      "kind": "compliance",
      "materials": [
        "written safety programs binder",
        "OSHA 300/300A logs",
        "SDS binder",
        "training records"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Ask the inspector for photo identification and a business card; note the agency, name, and badge number before anything else happens.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify credentials and remain courteous"
        },
        {
          "detail": "Do not leave the inspector waiting unattended; page or call the owner/office manager to come to the front immediately.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Immediately notify the practice owner or office manager"
        },
        {
          "detail": "A licensed practice owner or the designated management representative — never front desk alone — conducts the opening conference and stays with the inspector for the visit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner or authorized manager takes over as the point of contact.",
            "role": "practice-owner or designated manager",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner or authorized manager takes over as the point of contact"
        },
        {
          "detail": "Ask whether the visit is a complaint-driven, programmed, or referral inspection, and what records or areas the inspector wants to see.\n\nWhy: Knowing the scope lets the practice produce exactly what is requested rather than volunteering unrelated records.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hold the opening conference and learn the inspection scope",
          "why": "Knowing the scope lets the practice produce exactly what is requested rather than volunteering unrelated records."
        },
        {
          "detail": "Does the inspector request written programs, logs, or a facility walkthrough?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "records",
              "label": "Requests written programs and logs"
            },
            {
              "goto": "s7",
              "id": "walkthrough",
              "label": "Requests a facility walkthrough"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Does the inspector request written programs, logs, or a facility walkthrough?"
        },
        {
          "detail": "Retrieve the written safety programs, OSHA 300/300A logs, SDS binder, or training records that were specifically asked for; make copies rather than surrendering originals.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Produce the specific documents requested"
        },
        {
          "detail": "A management representative accompanies the inspector at all times, takes parallel notes and photos of anything the inspector photographs.\n\nWhy: A contemporaneous record protects the practice if findings are later disputed.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escort the inspector during any walkthrough",
          "why": "A contemporaneous record protects the practice if findings are later disputed."
        },
        {
          "detail": "Listen for any apparent violations discussed, ask clarifying questions, and request the inspector's contact information for follow-up.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Attend the closing conference"
        },
        {
          "detail": "Record the date, inspector identity, areas/documents reviewed, and any preliminary findings or citation deadlines mentioned.\n\nRecord: inspection visit log — date, inspector, scope, findings, deadlines",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the visit and any citation timeline"
        },
        {
          "detail": "Inspection response completed and documented",
          "id": "s10",
          "kind": "step",
          "title": "Inspection response completed and documented"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "OSHA or Cal/OSHA inspector arrives unannounced — A compliance officer presents credentials at the front desk.",
      "title": "OSHA or Cal/OSHA inspector arrives unannounced",
      "trigger": "A compliance officer presents credentials at the front desk",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "OSHA General Duty Clause 29 U.S.C. §654(a)(1) and OSHA ergonomics guidance for dental settings (public domain)",
          "source": "OSHA General Duty Clause 29 U.S.C. §654(a)(1) and OSHA ergonomics guidance for dental settings (public domain)",
          "url": "https://www.osha.gov/ergonomics"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA IIPP Title 8 §3203; Bloodborne Pathogens §5193; Aerosol Transmissible Diseases §5199; Workplace Violence Prevention Labor Code §6401.9",
          "source": "Cal/OSHA IIPP Title 8 §3203; Bloodborne Pathogens §5193; Aerosol Transmissible Diseases §5199; Workplace Violence Prevention Labor Code §6401.9",
          "url": "https://www.dir.ca.gov/title8/3203.html"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osha-015",
      "kind": "compliance",
      "materials": [
        "ergonomic self-assessment checklist",
        "operatory stool and loupes adjustment guide",
        "workstation photos"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "hygienist",
        "assistant",
        "dentist",
        "office-manager",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Listen to the staff member describe the pain, when it started, and which tasks or positions make it worse.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the complaint or note the annual review is due"
        },
        {
          "detail": "Check chair height, magnification loupe fit and angle, instrument reach distance, patient chair positioning, and whether the staff member is twisting or reaching repeatedly.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review the staff member's operatory setup and posture"
        },
        {
          "detail": "Does the complaint suggest a possible work-related injury needing medical evaluation?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "self-managed",
              "label": "Mild discomfort — ergonomic adjustment likely sufficient"
            },
            {
              "goto": "s8",
              "id": "needs-eval",
              "label": "Persistent or worsening pain — refer for medical evaluation"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "title": "Does the complaint suggest a possible work-related injury needing medical evaluation?"
        },
        {
          "detail": "Reposition the stool, adjust loupe angle/working distance, move the instrument tray closer, or introduce a support mat/saddle seating as appropriate.\n\nWhy: Sustained awkward posture and repetitive motion are the documented drivers of dental ergonomic injury; adjusting the workstation addresses the cause, not just the symptom.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Adjust the workstation and demonstrate corrected posture",
          "why": "Sustained awkward posture and repetitive motion are the documented drivers of dental ergonomic injury; adjusting the workstation addresses the cause, not just the symptom."
        },
        {
          "detail": "Follow up with the staff member after two to four weeks of the adjusted setup to confirm symptoms have improved.",
          "id": "s5",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1814400,
          "title": "Check back in two to four weeks"
        },
        {
          "detail": "Log the complaint, workstation changes made, and follow-up outcome in the ergonomics review file.\n\nRecord: ergonomic risk review log — complaint, adjustments, follow-up result",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the review and adjustments made"
        },
        {
          "detail": "Ergonomic review completed and documented",
          "id": "s7",
          "kind": "step",
          "title": "Ergonomic review completed and documented"
        },
        {
          "detail": "Provide the staff member information on seeking evaluation and note this may become an OSHA-recordable case if a physician confirms a work-related musculoskeletal disorder.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Refer to occupational medicine or the employee's own physician"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Ergonomic risk review after a repetitive-strain or musculoskeletal complaint — A hygienist, assistant or dentist reports persistent neck, back, wrist or shoulder pain related to chairside work, or the annual ergonomics review is due.",
      "title": "Ergonomic risk review after a repetitive-strain or musculoskeletal complaint",
      "trigger": "A hygienist, assistant or dentist reports persistent neck, back, wrist or shoulder pain related to chairside work, or the annual ergonomics review is due",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "public_domain",
          "label": "NIH/NIAID anaphylaxis emergency-care guidance — epinephrine as first-line treatment (public domain)",
          "source": "NIH/NIAID anaphylaxis emergency-care guidance — epinephrine as first-line treatment (public domain)",
          "url": "https://www.niaid.nih.gov/diseases-conditions/anaphylaxis"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "osha-016",
      "kind": "compliance",
      "materials": [
        "nitrile and other non-latex glove options",
        "hypoallergenic material alternatives list",
        "occupational health referral list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "compliance-officer",
        "hr",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Ask when the rash, hives, or wheeze started, whether it worsens during or after glove use, and whether the staff member has a known latex allergy.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Take the report seriously and document symptoms"
        },
        {
          "detail": "Is there any sign of a severe or systemic allergic reaction?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "mild",
              "label": "Localized skin irritation only"
            },
            {
              "goto": "s8",
              "id": "severe",
              "label": "Difficulty breathing, facial swelling, or widespread hives"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Is there any sign of a severe or systemic allergic reaction?"
        },
        {
          "detail": "Provide nitrile or another non-latex glove option and remove latex products from that staff member's immediate work area.\n\nWhy: Continued exposure risks progression from contact dermatitis to a systemic latex allergy.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Switch the staff member to non-latex gloves immediately",
          "why": "Continued exposure risks progression from contact dermatitis to a systemic latex allergy."
        },
        {
          "detail": "Check acrylics, disinfectants, and other chemicals the staff member routinely handles for known skin-sensitizing ingredients per their SDS.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review other materials the staff member handles for possible sensitizers"
        },
        {
          "detail": "Do symptoms persist after switching gloves and materials?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "resolved",
              "label": "Symptoms resolved after the switch"
            },
            {
              "goto": "s9",
              "id": "persists",
              "label": "Symptoms persist — refer for allergy evaluation"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Do symptoms persist after switching gloves and materials?"
        },
        {
          "detail": "Log the reported symptoms, materials switched, and outcome in the occupational health file, kept separate from the general personnel file.\n\nRecord: occupational health file — sensitization report, glove/material switch, outcome",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Document the sensitization report and accommodations made"
        },
        {
          "detail": "Sensitization addressed and accommodated",
          "id": "s7",
          "kind": "step",
          "title": "Sensitization addressed and accommodated"
        },
        {
          "detail": "Facial or throat swelling, difficulty breathing, or widespread hives after exposure can signal anaphylaxis — call 911 immediately, and if the office emergency kit stocks an epinephrine auto-injector, administer intramuscular epinephrine right away per the practice's written emergency protocol; epinephrine does not wait for EMS to arrive.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 for signs of anaphylaxis.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 for signs of anaphylaxis"
        },
        {
          "detail": "Provide the staff member a referral for formal allergy testing and note the case may need OSHA 300 log evaluation if work-related sensitization is confirmed.",
          "id": "s9",
          "kind": "step",
          "role": "hr",
          "title": "Refer to an allergist or occupational medicine provider"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Staff member develops latex, glove or acrylic dermatitis or sensitization — A team member reports recurring hand rash, hives or wheeze linked to gloves or materials.",
      "title": "Staff member develops latex, glove or acrylic dermatitis or sensitization",
      "trigger": "A team member reports recurring hand rash, hives or wheeze linked to gloves or materials",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA Injury and Illness Prevention Program Title 8 CCR §3203",
          "source": "Cal/OSHA Injury and Illness Prevention Program Title 8 CCR §3203",
          "url": "https://www.dir.ca.gov/title8/3203.html"
        },
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "osha-017",
      "kind": "compliance",
      "materials": [
        "written IIPP document",
        "hazard inspection checklist",
        "hazard correction log",
        "employee training sign-in sheet",
        "prior year's inspection records"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "practice-owner",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Locate the practice's written Injury and Illness Prevention Program document and the log of hazards corrected since the last review.\n\nWhy: §3203 requires every California employer to maintain a written, effective IIPP and be able to produce it on request.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the current written IIPP",
          "why": "§3203 requires every California employer to maintain a written, effective IIPP and be able to produce it on request."
        },
        {
          "detail": "Walk every operatory, sterilization area, break room, and storage/utility area checking: exposed wiring, blocked exits, unlabeled chemical containers, missing eyewash access, slip/trip hazards, unsecured oxygen or gas cylinders, and fire extinguisher inspection tags current.\n\nWhy: §3203 requires periodic scheduled inspections to identify unsafe conditions and unsafe work practices, not only a paper review.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "hazard inspection checklist"
          ],
          "role": "compliance-officer",
          "title": "Conduct a physical hazard-inspection walkthrough",
          "why": "§3203 requires periodic scheduled inspections to identify unsafe conditions and unsafe work practices, not only a paper review."
        },
        {
          "detail": "Record each hazard, its location, date found, and target correction date in the hazard correction log.\n\nRecord: hazard description, location, found date, target correction date in the hazard correction log",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log every hazard found"
        },
        {
          "detail": "Decide whether the hazard can be fixed same-day (relabel a container, clear an exit) or needs budget/vendor scheduling (rewiring, new eyewash station).",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "immediate",
              "label": "Correct immediately"
            },
            {
              "goto": "s10",
              "id": "scheduled",
              "label": "Needs budget or vendor"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the hazard correctable immediately with on-hand resources?"
        },
        {
          "detail": "Fix the hazard, then update the hazard correction log with the correction date and who performed it.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Correct the hazard and mark it closed"
        },
        {
          "detail": "Check the training sign-in sheet against the current staff roster.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "current",
              "label": "All staff current"
            },
            {
              "goto": "s12",
              "id": "lapsed",
              "label": "One or more staff lapsed"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is annual IIPP training current for all staff?"
        },
        {
          "detail": "Revise the IIPP with any new hazards, procedures, or responsible-person changes since the last review, and date the revision.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the written IIPP document"
        },
        {
          "detail": "Store the completed hazard inspection checklist, correction log, training sign-in sheet, and updated IIPP together with this year's review date.\n\nRecord: review date, inspection checklist, correction log, training roster, IIPP revision in the compliance file",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the annual review record"
        },
        {
          "detail": "Annual IIPP review complete",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual IIPP review complete"
        },
        {
          "detail": "Present the hazard, risk, and estimated cost to the practice owner for approval before scheduling the fix.\n\nWhy: A capital or vendor spend needs the person who controls the budget to sign off before it is committed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route unbudgeted hazard corrections for owner approval.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Route unbudgeted hazard corrections for owner approval",
          "why": "A capital or vendor spend needs the person who controls the budget to sign off before it is committed."
        },
        {
          "detail": "Book the vendor or repair and put a temporary control in place (barrier tape, signage, restricted access) until the permanent fix is complete.\n\nWhy: An interim control keeps staff and patients safe while the permanent correction is pending.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the vendor or capital fix with an interim control",
          "why": "An interim control keeps staff and patients safe while the permanent correction is pending."
        },
        {
          "detail": "Book the lapsed staff for IIPP training covering hazard recognition, reporting, and emergency procedures within 30 days.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule refresher IIPP training"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "California Injury and Illness Prevention Program review and hazard inspection (CA addendum) — The IIPP anniversary, a new hazard is identified, or a workplace injury occurs in a California office.",
      "title": "California Injury and Illness Prevention Program review and hazard inspection (CA addendum)",
      "trigger": "The IIPP anniversary, a new hazard is identified, or a workplace injury occurs in a California office",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA Workplace Violence Prevention in Health Care, Labor Code §6401.9 and Title 8 CCR §3342",
          "source": "Cal/OSHA Workplace Violence Prevention in Health Care, Labor Code §6401.9 and Title 8 CCR §3342",
          "url": "https://www.dir.ca.gov/dosh/dosh_publications/WPV-HealthCareFinal.pdf"
        },
        {
          "kind": "regulation",
          "label": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "source": "OSHA Emergency Action Plan 1910.38 and Fire Prevention Plan 1910.39; Recordkeeping 29 CFR 1904",
          "url": "https://www.ecfr.gov/current/title-29/part-1904"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "osha-018",
      "kind": "compliance",
      "materials": [
        "written workplace violence prevention plan",
        "violent incident log",
        "training sign-in sheet",
        "panic button or duress alarm test log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Determine whether this run is the yearly plan review/training cycle or triggered by an actual violent incident.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "annual",
              "label": "Scheduled annual review"
            },
            {
              "goto": "s8",
              "id": "incident",
              "label": "Incident occurred"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is this a scheduled annual review or a logged incident?"
        },
        {
          "detail": "Retrieve the current plan and confirm it names a person responsible for implementation, reporting procedures, and post-incident response.\n\nWhy: §3342 requires a written plan with specific named responsibilities, not a generic statement of policy.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the written workplace violence prevention plan",
          "why": "§3342 requires a written plan with specific named responsibilities, not a generic statement of policy."
        },
        {
          "detail": "Trigger each duress alarm or panic button in the office and confirm it reaches the intended responder (front desk, dispatch, or security service).",
          "id": "s3",
          "kind": "step",
          "materials": [
            "panic button or duress alarm test log"
          ],
          "role": "office-manager",
          "title": "Test panic buttons or duress alarms"
        },
        {
          "detail": "Train all staff on recognizing early warning signs, de-escalation, reporting procedures, and the location of alarms and exits.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "training sign-in sheet"
          ],
          "role": "compliance-officer",
          "title": "Deliver annual workplace violence training"
        },
        {
          "detail": "Check the plan against any incidents logged in the past year and update controls or contacts as needed.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review and update the plan for the year"
        },
        {
          "detail": "Store the updated plan, training sign-in sheet, alarm test log, and (if applicable) the incident log entry together with the review date.\n\nRecord: review date, plan version, training roster, alarm test results, incident log reference in the compliance file",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the annual review or incident record"
        },
        {
          "detail": "Workplace violence prevention cycle complete",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Workplace violence prevention cycle complete"
        },
        {
          "detail": "If anyone is armed, injured, or the threat is ongoing, call 911 immediately before doing anything else. Otherwise move all staff and patients away from the individual involved.\n\nWhy: A workplace violence incident can escalate to a life-safety emergency; the emergency call takes priority over documentation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the scene is safe; call 911 if a weapon, injury, or ongoing threat is present.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm the scene is safe; call 911 if a weapon, injury, or ongoing threat is present",
          "why": "A workplace violence incident can escalate to a life-safety emergency; the emergency call takes priority over documentation."
        },
        {
          "detail": "Record date, time, location, individuals involved (by role, not patient clinical data), what happened, and any injuries in the violent incident log.\n\nRecord: date, time, location, roles involved, description, injuries in the violent incident log",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident within 24 hours"
        },
        {
          "detail": "Meet with everyone present within a few days to review what happened, offer support resources, and identify plan gaps.\n\nWhy: A debrief surfaces near-miss lessons while memory is fresh and gives staff a chance to flag needed support.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hold a post-incident debrief with affected staff",
          "why": "A debrief surfaces near-miss lessons while memory is fresh and gives staff a chance to flag needed support."
        },
        {
          "detail": "Revise the plan's controls (staffing, alarm placement, escalation contacts) if the debrief found a gap.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Update the written plan with lessons learned"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Workplace violence prevention plan, incident log and annual training (CA addendum) — The annual plan review and training date arrives, or a violent incident must be logged.",
      "title": "Workplace violence prevention plan, incident log and annual training (CA addendum)",
      "trigger": "The annual plan review and training date arrives, or a violent incident must be logged",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA Aerosol Transmissible Diseases standard, Title 8 CCR §5199",
          "source": "Cal/OSHA Aerosol Transmissible Diseases standard, Title 8 CCR §5199",
          "url": "https://www.dir.ca.gov/title8/5199.html"
        },
        {
          "kind": "public_domain",
          "label": "CDC guidance on respiratory pathogen exposure control (public domain)",
          "source": "CDC guidance on respiratory pathogen exposure control (public domain)",
          "url": "https://www.cdc.gov/infection-control/hcp/healthcare-personnel-guidance/index.html"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "osha-019",
      "kind": "compliance",
      "materials": [
        "written aerosol transmissible disease (ATD) plan",
        "N95 respirators",
        "exposure notification log",
        "local public health department contact list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "dentist",
        "front-desk",
        "office-manager",
        "assistant",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Verify the specific trigger (advisory, disclosed symptoms, or later diagnosis) and retrieve the practice's written aerosol transmissible disease plan.\n\nWhy: §5199 requires a written plan that is activated by defined triggers, not an ad hoc response.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the trigger and pull the written ATD plan",
          "why": "§5199 requires a written plan that is activated by defined triggers, not an ad hoc response."
        },
        {
          "detail": "Determine whether the trigger involves a patient physically present right now versus a retrospective notification about a past visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "present",
              "label": "Patient currently in office"
            },
            {
              "goto": "s6",
              "id": "retrospective",
              "label": "Retrospective notification"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is a symptomatic patient currently in the office?"
        },
        {
          "detail": "Offer the patient a surgical mask and move them to a private room or the least-trafficked area away from other patients while arrangements are made.\n\nWhy: Source control (masking) and physical distancing reduce airborne transmission risk immediately, before any diagnosis is confirmed.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Mask the patient and move them to a private area",
          "why": "Source control (masking) and physical distancing reduce airborne transmission risk immediately, before any diagnosis is confirmed."
        },
        {
          "detail": "Any staff member who must interact with the patient wears an N95 or higher, not a surgical mask.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "N95 respirators"
          ],
          "role": "assistant",
          "title": "Staff entering the room don fit-tested N95 respirators"
        },
        {
          "detail": "If treatment is not urgent, reschedule after medical clearance; if urgent, refer for medical evaluation before continuing dental treatment.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Reschedule non-urgent treatment or refer to medical evaluation"
        },
        {
          "detail": "Review the appointment schedule and treatment room log to list every staff member present without an N95 during the exposure window.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Identify staff who had unprotected exposure"
        },
        {
          "detail": "For each staff member: confirm respirator use during contact, ask about symptoms, and check vaccination/immunity status where relevant (e.g., measles).",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Assess each exposed staff member"
        },
        {
          "detail": "Based on exposure assessment, decide whether any staff member should be referred for medical evaluation or excluded from patient contact pending clearance.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "no-referral",
              "label": "No referral needed"
            },
            {
              "goto": "s12",
              "id": "referral",
              "label": "Referral or exclusion needed"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does any staff member need medical evaluation or exclusion from work?"
        },
        {
          "detail": "For a reportable airborne disease (e.g., confirmed TB or measles), contact the local public health department per the ATD plan's reporting list.\n\nWhy: Certain airborne diseases are reportable conditions independent of the OSHA exposure obligation.",
          "id": "s9",
          "kind": "step",
          "materials": [
            "local public health department contact list"
          ],
          "role": "compliance-officer",
          "title": "Notify local public health department if required",
          "why": "Certain airborne diseases are reportable conditions independent of the OSHA exposure obligation."
        },
        {
          "detail": "Log the trigger, staff assessed, referrals made, and public health notification in the exposure notification log.\n\nRecord: trigger event, staff assessed, referrals, public health notification in the exposure notification log",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the activation and follow-up"
        },
        {
          "detail": "ATD plan activation and follow-up complete",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "ATD plan activation and follow-up complete"
        },
        {
          "detail": "Provide the staff member with the exposure details in writing and refer them to their physician or occupational health provider; exclude from patient contact per the ATD plan pending clearance.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Refer staff member for medical evaluation"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Aerosol transmissible disease plan activation and staff exposure follow-up (CA addendum) — A public-health advisory for a respiratory pathogen is issued, a patient discloses active TB or measles symptoms, or a patient treated earlier is later diagnosed with an airborne illness.",
      "title": "Aerosol transmissible disease plan activation and staff exposure follow-up (CA addendum)",
      "trigger": "A public-health advisory for a respiratory pathogen is issued, a patient discloses active TB or measles symptoms, or a patient treated earlier is later diagnosed with an airborne illness",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "public_domain",
          "label": "CDC/USPHS post-exposure prophylaxis guidelines for HIV, HBV, HCV (public domain)",
          "source": "CDC/USPHS post-exposure prophylaxis guidelines for HIV, HBV, HCV (public domain)",
          "url": "https://www.cdc.gov/mmwr/volumes/65/rr/rr6509a1.htm"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osha-020",
      "kind": "compliance",
      "materials": [
        "first aid supplies",
        "post-exposure evaluation referral form",
        "incident report form",
        "patient disclosure script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The moment a torn glove and bleeding wound contact is recognized, stop treatment, step back from the patient, and change gloves.\n\nWhy: Continuing treatment extends the exposure window for both provider and patient.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Stop the procedure immediately",
          "why": "Continuing treatment extends the exposure window for both provider and patient."
        },
        {
          "detail": "Immediately rinse the patient's oral cavity, or flush the contacted mucosa or tissue, thoroughly with water to reduce contact time with the provider's blood.\n\nWhy: The patient is the person actually exposed to the provider's blood; irrigation reduces exposure dose the same way it would for any splash exposure.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Rinse the patient's mouth or affected area with water",
          "why": "The patient is the person actually exposed to the provider's blood; irrigation reduces exposure dose the same way it would for any splash exposure."
        },
        {
          "detail": "Wash the wound thoroughly with soap and water; do not apply caustic agents or attempt to express fluid by squeezing.\n\nWhy: Standard first aid; aggressive squeezing does not reduce transmission risk and can worsen tissue injury.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "first aid supplies"
          ],
          "role": "dentist",
          "title": "Provide first aid to the provider's wound",
          "why": "Standard first aid; aggressive squeezing does not reduce transmission risk and can worsen tissue injury."
        },
        {
          "detail": "The treating dentist (or another licensed provider on site) confirms the exposure classification and reviews the disclosure and referral plan before the patient conversation happens.\n\nWhy: This event carries clinical and legal consequences for both provider and patient; a licensed clinician must own the assessment before anything is communicated or submitted.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider confirms exposure occurred and next steps before disclosure.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider confirms exposure occurred and next steps before disclosure",
          "why": "This event carries clinical and legal consequences for both provider and patient; a licensed clinician must own the assessment before anything is communicated or submitted."
        },
        {
          "detail": "Explain to the patient, in plain language, that a provider's blood contacted their tissue, what steps are being taken, and that they may wish to consult their own physician.\n\nWhy: Patients have a right to know about an exposure that occurred during their treatment; prompt, honest disclosure is both an ethical and risk-management obligation.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "patient disclosure script"
          ],
          "role": "dentist",
          "title": "Disclose the exposure to the patient the same visit",
          "why": "Patients have a right to know about an exposure that occurred during their treatment; prompt, honest disclosure is both an ethical and risk-management obligation."
        },
        {
          "detail": "Provide the patient with information on where they can seek voluntary evaluation and baseline testing, and document that the offer was made.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Offer the patient a referral for evaluation and testing"
        },
        {
          "detail": "Send the provider to the designated occupational health clinic or physician for evaluation and, if indicated, baseline testing and counseling on post-exposure prophylaxis timing.\n\nWhy: 29 CFR 1910.1030 entitles the exposed employee to confidential medical evaluation regardless of who was exposed to whom.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "post-exposure evaluation referral form"
          ],
          "role": "compliance-officer",
          "title": "Refer the provider for post-exposure medical evaluation",
          "why": "29 CFR 1910.1030 entitles the exposed employee to confidential medical evaluation regardless of who was exposed to whom."
        },
        {
          "detail": "Complete the incident report form with date, time, description, patient disclosure confirmation, and referrals made; file separately from the patient's clinical chart per confidentiality practice.\n\nRecord: incident description, disclosure confirmation, referrals in the incident report form and provider's confidential medical record",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the incident and disclosure"
        },
        {
          "detail": "Provider-to-patient exposure response complete",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Provider-to-patient exposure response complete"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Provider-to-patient blood exposure (staff bleeds into a patient's mouth) — A glove tears and a bleeding staff wound contacts a patient's mucosa or open tissue.",
      "title": "Provider-to-patient blood exposure (staff bleeds into a patient's mouth)",
      "trigger": "A glove tears and a bleeding staff wound contacts a patient's mucosa or open tissue",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "osha-021",
      "kind": "compliance",
      "materials": [
        "sharps container",
        "incident report form",
        "waste stream audit checklist",
        "non-employee exposure notification packet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Determine whether this event is a non-employee needlestick injury or a discovery of a sharp in the wrong waste stream with no injury.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "injury",
              "label": "Non-employee was stuck"
            },
            {
              "goto": "s10",
              "id": "no-injury",
              "label": "Sharp found, no injury"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was a person stuck, or was a sharp only found unused?"
        },
        {
          "detail": "Wash the wound with soap and water; do not squeeze or apply caustic agents.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Provide immediate first aid"
        },
        {
          "detail": "Because the injured person is not an employee, notify the practice owner before referring for medical evaluation, since third-party liability and insurance carrier notification decisions follow from this.\n\nWhy: A non-employee exposure carries potential liability exposure that the person with authority over the practice's insurance and legal relationships should be aware of immediately.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner or office manager authorizes referral and any third-party notification.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner or office manager authorizes referral and any third-party notification",
          "why": "A non-employee exposure carries potential liability exposure that the person with authority over the practice's insurance and legal relationships should be aware of immediately."
        },
        {
          "detail": "Provide the non-employee with a written summary of the exposure and refer them to urgent care or their own physician for evaluation; offer to cover reasonable evaluation costs per practice policy.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "non-employee exposure notification packet"
          ],
          "role": "compliance-officer",
          "title": "Refer the non-employee for medical evaluation"
        },
        {
          "detail": "Review which operatory or process the trash or laundry bag came from and identify which step in sharps handling failed.\n\nWhy: A single stray sharp usually points to a process gap (e.g., an overfilled container, a missed final sweep) that will recur if not corrected.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Trace how the sharp entered the wrong waste stream",
          "why": "A single stray sharp usually points to a process gap (e.g., an overfilled container, a missed final sweep) that will recur if not corrected."
        },
        {
          "detail": "Check every operatory and processing area for correctly placed, non-overfilled sharps containers and confirm the trash/laundry handling procedure with staff.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "waste stream audit checklist"
          ],
          "role": "compliance-officer",
          "title": "Audit the current waste stream and sharps container placement"
        },
        {
          "detail": "Add or relocate sharps containers, retrain the specific staff involved, or adjust the final-sweep procedure based on what the trace found.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Implement a corrective action"
        },
        {
          "detail": "Complete the incident report form with what was found, who was affected (if anyone), the trace findings, and the corrective action taken.\n\nRecord: incident description, affected person (if any), trace findings, corrective action in the incident report form",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the incident and corrective action"
        },
        {
          "detail": "Sharps waste-stream incident response complete",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Sharps waste-stream incident response complete"
        },
        {
          "detail": "Using appropriate PPE and a rigid container or tongs, move the sharp into a proper sharps container immediately.",
          "id": "s10",
          "kind": "step",
          "materials": [
            "sharps container"
          ],
          "role": "office-manager",
          "title": "Secure the sharp and dispose of it properly"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Sharps found in regular trash or laundry, or a contractor, cleaner or visitor is stuck — A janitor reports a needlestick from an office bag, or a used needle is found in the regular waste.",
      "title": "Sharps found in regular trash or laundry, or a contractor, cleaner or visitor is stuck",
      "trigger": "A janitor reports a needlestick from an office bag, or a used needle is found in the regular waste",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        },
        {
          "kind": "regulation",
          "label": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "source": "OSHA Hazard Communication 29 CFR 1910.1200; PPE 1910.132; Respiratory Protection 1910.134; Eyewash 1910.151(c)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1200"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "osha-022",
      "kind": "compliance",
      "materials": [
        "biohazard laundry bags",
        "PPE",
        "designated laundering vendor or on-site laundering log",
        "spare clean gowns/scrubs"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Determine whether this run is a proactive correction of a proposed home-laundering, or handling of already-soiled PPE.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "proposed-home",
              "label": "Staff proposes taking PPE home"
            },
            {
              "goto": "s5",
              "id": "soiled",
              "label": "PPE is visibly contaminated now"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a staff member proposing to take PPE home, or is PPE already visibly contaminated?"
        },
        {
          "detail": "Tell the staff member that contaminated PPE and reusable protective clothing must be laundered by the practice or its designated laundering vendor, never taken home.\n\nWhy: 1910.1030(d)(3)(v) requires the employer to launder or arrange laundering of contaminated protective clothing; sending it home shifts a bloodborne-pathogen hazard into the employee's household.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Explain that employer-provided PPE is never laundered at home",
          "why": "1910.1030(d)(3)(v) requires the employer to launder or arrange laundering of contaminated protective clothing; sending it home shifts a bloodborne-pathogen hazard into the employee's household."
        },
        {
          "detail": "Issue the staff member a spare clean gown or scrub set from inventory so they are not without protective clothing for the rest of the shift.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "spare clean gowns/scrubs"
          ],
          "role": "office-manager",
          "title": "Provide a clean replacement gown or scrub"
        },
        {
          "detail": "Contaminated PPE handled correctly",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Contaminated PPE handled correctly"
        },
        {
          "detail": "Have the staff member remove the contaminated gown or scrub item where it was soiled and place it directly into a labeled biohazard laundry bag.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "biohazard laundry bags"
          ],
          "role": "all-staff",
          "title": "Remove and bag the contaminated item at the point of use"
        },
        {
          "detail": "Place the sealed bag in the practice's designated storage area, not in a general trash or break-room area, pending laundering pickup.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Store the bag in the designated soiled-linen area"
        },
        {
          "detail": "Confirm the bag is scheduled for pickup by the contracted laundering vendor, or processed through the practice's own compliant in-house laundering process.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "designated laundering vendor or on-site laundering log"
          ],
          "role": "compliance-officer",
          "title": "Arrange laundering through the designated vendor or in-house process"
        },
        {
          "detail": "Note the date, item, and disposition (vendor pickup or in-house wash) in the laundering log.\n\nRecord: date, item, disposition in the laundering log",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the laundering event"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Contaminated clothing and reusable PPE laundering (employer-provided, never at home) — Gowns or scrubs are visibly contaminated, or a staff member proposes taking clinic gowns home to wash.",
      "title": "Contaminated clothing and reusable PPE laundering (employer-provided, never at home)",
      "trigger": "Gowns or scrubs are visibly contaminated, or a staff member proposes taking clinic gowns home to wash",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "source": "OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 (post-exposure evaluation, sharps injury log, hepatitis B)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.1030"
        }
      ],
      "class": "osha-workplace-safety",
      "department": "compliance",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "osha-023",
      "kind": "compliance",
      "materials": [
        "designated break-room signage",
        "separate labeled refrigerator for food",
        "staff policy handout"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Determine whether food/drink was found in a clinical or processing area, or staff food was found in a refrigerator that also holds drugs or clinical specimens.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "clinical-area",
              "label": "Food/drink in operatory or sterilization area"
            },
            {
              "goto": "s5",
              "id": "shared-fridge",
              "label": "Staff food in drug/specimen refrigerator"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Where was the violation found?"
        },
        {
          "detail": "Take the item out of the clinical or processing area and dispose of or relocate it to the designated break room.\n\nWhy: 1910.1030(d)(2)(ix) prohibits eating, drinking, and related activities in work areas where there is reasonable likelihood of occupational exposure to blood or other potentially infectious materials.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Remove the food or drink item immediately",
          "why": "1910.1030(d)(2)(ix) prohibits eating, drinking, and related activities in work areas where there is reasonable likelihood of occupational exposure to blood or other potentially infectious materials."
        },
        {
          "detail": "Post or re-share the break-room-only policy handout and point out where the designated break room and food refrigerator are located.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "designated break-room signage",
            "staff policy handout"
          ],
          "role": "office-manager",
          "title": "Remind staff of the food and drink policy"
        },
        {
          "detail": "Food and drink policy enforced",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Food and drink policy enforced"
        },
        {
          "detail": "Take the staff food item out and place it in the separate, labeled break-room refrigerator.\n\nWhy: Storing food with drugs, chemicals, or biological specimens risks contamination and confuses staff about what is safe to consume.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Remove staff food from the drug or specimen refrigerator",
          "why": "Storing food with drugs, chemicals, or biological specimens risks contamination and confuses staff about what is safe to consume."
        },
        {
          "detail": "Check whether the break room has its own refrigerator clearly labeled for staff food, distinct from any clinical refrigerator.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "has-one",
              "label": "Separate fridge exists"
            },
            {
              "goto": "s7",
              "id": "missing",
              "label": "No separate fridge"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the office have a separate, labeled food refrigerator?"
        },
        {
          "detail": "Purchase or designate a refrigerator solely for staff food in the break room and label it clearly.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "separate labeled refrigerator for food"
          ],
          "role": "office-manager",
          "title": "Arrange for a dedicated food refrigerator"
        }
      ],
      "subclass": "osha-workplace-safety-and-occupational-exposure",
      "summary": "Food and drink prohibition in clinical and processing areas; break-room and refrigerator controls — Food or a coffee cup is found in an operatory or sterilization area, or staff food is stored in the drug refrigerator.",
      "title": "Food and drink prohibition in clinical and processing areas; break-room and refrigerator controls",
      "trigger": "Food or a coffee cup is found in an operatory or sterilization area, or staff food is stored in the drug refrigerator",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)",
          "source": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)"
        },
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "osx-001",
      "kind": "clinical",
      "materials": [
        "updated medical history form",
        "current periapical or panoramic radiograph",
        "blood pressure cuff",
        "consent form",
        "difficulty-scoring reference (1-5 scale keyed to root form, angulation, bone density, access, adjacent anatomy)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the medical history form is current, flag anticoagulants, bisphosphonates, uncontrolled diabetes, cardiac conditions, and pregnancy; note any allergy to local anesthetic.\n\nWhy: Systemic risk factors change anesthetic choice, hemostasis planning, and whether medical clearance is needed before proceeding.\n\nRecord: updated medical history and flagged risk factors in the chart",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Review updated medical history and medications",
          "why": "Systemic risk factors change anesthetic choice, hemostasis planning, and whether medical clearance is needed before proceeding."
        },
        {
          "detail": "Verify a periapical or panoramic image taken within the practice's current-image window shows the full root and adjacent anatomy; order a new one if the existing image is outdated or does not show the root apex.\n\nWhy: Root morphology, proximity to the sinus or nerve canal, and bone density cannot be assessed safely without a current image.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm a current diagnostic radiograph is available",
          "why": "Root morphology, proximity to the sinus or nerve canal, and bone density cannot be assessed safely without a current image."
        },
        {
          "detail": "Score the case 1 (straightforward) to 5 (highly complex) using root form, angulation, bone density, access, and adjacent anatomy as the five scoring factors; record whether the case is expected to be a simple or surgical extraction.\n\nWhy: The difficulty score drives time-blocking, instrument selection, and the decision below on whether to refer.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Assign a difficulty score to the extraction",
          "why": "The difficulty score drives time-blocking, instrument selection, and the decision below on whether to refer."
        },
        {
          "detail": "Proceed in-office or refer out",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "proceed",
              "label": "Proceed with in-office extraction"
            },
            {
              "goto": "s9",
              "id": "refer",
              "label": "Refer to oral surgery (high difficulty score, medical risk, or nerve/sinus proximity)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "title": "Proceed in-office or refer out"
        },
        {
          "detail": "Confirm patient age/capacity from the chart before routing to the correct consenting party.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "adult",
              "label": "Adult patient with capacity — obtains own consent"
            },
            {
              "goto": "s11",
              "id": "minor",
              "label": "Minor patient — caregiver/guardian consent required"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient a minor requiring caregiver/guardian consent?"
        },
        {
          "detail": "Dentist explains the procedure, risks (bleeding, infection, dry socket, nerve injury, sinus involvement, need for further treatment), alternatives, and answers questions before the patient signs; the dentist countersigns.\n\nWhy: Consent is the licensed clinician's own act — it must be obtained by the treating dentist, not delegated or defaulted through.\n\nRecord: signed consent form filed in the chart",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain signed informed consent before proceeding.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain signed informed consent before proceeding",
          "why": "Consent is the licensed clinician's own act — it must be obtained by the treating dentist, not delegated or defaulted through."
        },
        {
          "detail": "Enter the difficulty score, planned procedure, anesthetic plan, and consent confirmation into the chart note.\n\nRecord: difficulty score, planned procedure (simple vs surgical), anesthetic plan, and consent confirmation entered in the chart note",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Document the finalized treatment plan"
        },
        {
          "detail": "Patient assessed, consented, and ready for the extraction protocol",
          "id": "s8",
          "kind": "step",
          "title": "Patient assessed, consented, and ready for the extraction protocol"
        },
        {
          "detail": "Send the radiograph, chart note, and reason for referral to the treatment coordinator for scheduling with oral surgery.\n\nRecord: referral reason and destination logged in the chart",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand the case to the referral coordinator"
        },
        {
          "detail": "Case referred, not extracted in-office",
          "id": "s10",
          "kind": "step",
          "title": "Case referred, not extracted in-office"
        },
        {
          "detail": "Dentist explains the procedure, risks (bleeding, infection, dry socket, nerve injury, sinus involvement, need for further treatment), alternatives, and answers questions before the parent, legal guardian, or authorized caregiver signs on the minor patient's behalf; the dentist countersigns.\n\nWhy: A minor cannot provide their own informed consent for a surgical procedure — a parent, legal guardian, or authorized caregiver must consent on the minor's behalf.\n\nRecord: signed consent form filed in the chart, noting the caregiver/guardian relationship to the patient",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain signed informed consent from the caregiver/guardian before proceeding.",
            "type": "safety"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain signed informed consent from the caregiver/guardian before proceeding",
          "why": "A minor cannot provide their own informed consent for a surgical procedure — a parent, legal guardian, or authorized caregiver must consent on the minor's behalf."
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Extraction pre-op assessment — medical risk, radiograph, difficulty score, consent — A tooth is planned for extraction.",
      "title": "Extraction pre-op assessment — medical risk, radiograph, difficulty score, consent",
      "trigger": "A tooth is planned for extraction",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)",
          "source": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)"
        },
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "per-patient",
      "id": "osx-002",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "elevators",
        "extraction forceps",
        "gauze",
        "suction",
        "sterile tray"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the signed consent from the pre-op assessment protocol is in the chart before administering anesthetic.\n\nWhy: No treatment step proceeds without the licensed clinician's own confirmed consent — never assumed from a prior visit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Verify signed consent is on file before anesthetic.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Verify signed consent is on file before anesthetic",
          "why": "No treatment step proceeds without the licensed clinician's own confirmed consent — never assumed from a prior visit."
        },
        {
          "detail": "Take blood pressure and pulse same-day (the pre-op assessment may have happened on an earlier visit); confirm no new medical changes since the pre-op assessment.\n\nWhy: Vitals and a medical-history recheck belong immediately before anesthetic administration, not only at the earlier pre-op assessment visit.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Check same-day vital signs before anesthetic",
          "why": "Vitals and a medical-history recheck belong immediately before anesthetic administration, not only at the earlier pre-op assessment visit."
        },
        {
          "detail": "Deliver the planned block or infiltration, aspirating before each injection to confirm the needle is not intravascular; wait for onset, and test soft-tissue anesthesia before instrumenting.\n\nWhy: Proceeding before full anesthesia causes pain and patient movement that increases fracture risk.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthetic and confirm profound anesthesia",
          "why": "Proceeding before full anesthesia causes pain and patient movement that increases fracture risk."
        },
        {
          "detail": "Use elevators to sever the periodontal ligament and begin mobilizing the tooth before applying forceps.\n\nWhy: Luxation reduces the force needed with forceps and lowers the chance of root fracture.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Luxate the tooth with elevators to expand the socket",
          "why": "Luxation reduces the force needed with forceps and lowers the chance of root fracture."
        },
        {
          "detail": "Seat forceps apically along the root, apply buccal-lingual and rotational pressure as anatomy allows, and deliver the tooth intact.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Apply forceps and deliver the tooth with controlled movements"
        },
        {
          "detail": "Tooth delivering as expected?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "continue-simple",
              "label": "Delivering normally — continue simple extraction"
            },
            {
              "goto": "s11",
              "id": "convert-surgical",
              "label": "Root resistant or fracturing — convert to surgical protocol"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "title": "Tooth delivering as expected?"
        },
        {
          "detail": "Confirm the full tooth including root apex was delivered; check the socket for retained fragments, bone irregularities, or a communication into the sinus (posterior maxilla); irrigate and check hemostasis.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Inspect the socket and extracted tooth"
        },
        {
          "detail": "Assistant places gauze for bite pressure and prepares written post-op instructions per the dedicated hemostasis protocol.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to post-extraction hemostasis and instructions protocol"
        },
        {
          "detail": "Enter the tooth extracted, anesthetic used, complications, socket findings, and instructions given into the chart note.\n\nRecord: tooth extracted, anesthetic used, any complications, socket findings, and post-op instructions given, entered in the chart note",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the completed procedure"
        },
        {
          "detail": "Simple extraction complete",
          "id": "s10",
          "kind": "step",
          "title": "Simple extraction complete"
        },
        {
          "detail": "Do not force a resistant root; move to the surgical extraction protocol (flap, sectioning) rather than risk uncontrolled fracture.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Continue the case under the surgical extraction protocol"
        },
        {
          "detail": "Case continues under surgical extraction protocol",
          "id": "s12",
          "kind": "step",
          "title": "Case continues under surgical extraction protocol"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Simple forceps extraction with post-op check — An erupted tooth with an intact crown and favorable root form.",
      "title": "Simple forceps extraction with post-op check",
      "trigger": "An erupted tooth with an intact crown and favorable root form",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)",
          "source": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)"
        },
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "osx-003",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "scalpel",
        "periosteal elevator",
        "surgical handpiece and burs",
        "elevators",
        "forceps",
        "sutures",
        "gauze",
        "suction"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the signed consent names surgical extraction (flap, bone removal, sectioning) and not only a simple extraction; re-consent if the case converted mid-visit.\n\nWhy: A surgical extraction carries materially different risks than a simple one and needs its own informed consent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent covers surgical extraction specifically.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent covers surgical extraction specifically",
          "why": "A surgical extraction carries materially different risks than a simple one and needs its own informed consent."
        },
        {
          "detail": "Test soft tissue and bone-adjacent anesthesia before incising; supplement if any area is under-anesthetized.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm profound anesthesia over the surgical field"
        },
        {
          "detail": "Make the planned incision and reflect the flap with a periosteal elevator to expose the surgical site, protecting adjacent soft tissue.\n\nWhy: Adequate access reduces the force needed downstream and protects nerves and adjacent teeth from instrument slippage.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Incise and reflect a mucoperiosteal flap",
          "why": "Adequate access reduces the force needed downstream and protects nerves and adjacent teeth from instrument slippage."
        },
        {
          "detail": "Use a surgical handpiece with copious irrigation to remove the minimum bone needed to expose the tooth for elevation or sectioning.\n\nWhy: Copious irrigation prevents thermal bone necrosis; minimizing bone removal preserves ridge volume for future restoration.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Remove buccal bone as needed for access",
          "why": "Copious irrigation prevents thermal bone necrosis; minimizing bone removal preserves ridge volume for future restoration."
        },
        {
          "detail": "Section the tooth or elevate whole?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "section",
              "label": "Section into roots/segments (multi-rooted or ankylosed tooth)"
            },
            {
              "goto": "s6",
              "id": "elevate-whole",
              "label": "Elevate and deliver whole (single conical root, adequate access)"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Section the tooth or elevate whole?"
        },
        {
          "detail": "Use elevators on each segment individually and deliver with forceps; confirm every planned segment has been removed.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Elevate and deliver all tooth segments"
        },
        {
          "detail": "Irrigate, remove granulation tissue and bone fragments, smooth sharp bony edges, and confirm no retained root tips or foreign material remain; check for sinus or nerve involvement.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Debride and inspect the socket"
        },
        {
          "detail": "Site condition after debridement",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "close-normal",
              "label": "Clean site — reposition flap and close"
            },
            {
              "goto": "s13",
              "id": "complication-found",
              "label": "Complication found (root tip, oroantral communication)"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "title": "Site condition after debridement"
        },
        {
          "detail": "Reposition the flap to its original position and place interrupted or continuous sutures for primary or partial closure as planned.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Reposition the flap and place sutures"
        },
        {
          "detail": "Assistant confirms hemostasis and begins written post-op instructions including suture-removal timing.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to post-extraction hemostasis and instructions protocol"
        },
        {
          "detail": "Enter the flap design, bone removed, sectioning performed, suture type and count, and complications into the chart note.\n\nRecord: flap design, bone removed, sectioning performed, suture type and count, and any complications, entered in the chart note",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the surgical procedure"
        },
        {
          "detail": "Surgical extraction complete",
          "id": "s12",
          "kind": "step",
          "title": "Surgical extraction complete"
        },
        {
          "detail": "Move to the fractured root tip or oroantral communication protocol as appropriate rather than closing over an unresolved finding.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the relevant complication protocol"
        },
        {
          "detail": "Case continues under a complication-specific protocol",
          "id": "s14",
          "kind": "step",
          "title": "Case continues under a complication-specific protocol"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Surgical extraction — flap, bone removal, sectioning, closure — A broken-down, ankylosed or multi-rooted tooth that cannot be delivered simply.",
      "title": "Surgical extraction — flap, bone removal, sectioning, closure",
      "trigger": "A broken-down, ankylosed or multi-rooted tooth that cannot be delivered simply",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent: CBCT/3D-imaging escalation when a panoramic image shows equivocal nerve-canal proximity signs — not tied to any institute or vendor protocol",
          "source": "Generic functional equivalent: CBCT/3D-imaging escalation when a panoramic image shows equivocal nerve-canal proximity signs — not tied to any institute or vendor protocol"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "osx-004",
      "kind": "clinical",
      "materials": [
        "panoramic radiograph",
        "referral form",
        "AAOMS/ADA third-molar assessment reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Assess angulation (mesioangular, distoangular, horizontal, vertical), depth of impaction, and proximity of the roots to the inferior alveolar nerve canal and, for uppers, the maxillary sinus.\n\nWhy: Nerve and sinus proximity are the primary drivers of surgical risk and the referral decision.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review the panoramic image for impaction pattern and root proximity",
          "why": "Nerve and sinus proximity are the primary drivers of surgical risk and the referral decision."
        },
        {
          "detail": "Darkening of the root, interruption of the canal's white lines, or canal deflection on the pano are signs worth clarifying with 3D imaging before committing to a treat-versus-refer call.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "clear",
              "label": "No nerve-proximity signs, or clearly low-risk on the panoramic alone"
            },
            {
              "goto": "s10",
              "id": "equivocal",
              "label": "Equivocal nerve-canal overlap/proximity signs — order 3D imaging first"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the panoramic show equivocal signs of nerve-canal proximity?"
        },
        {
          "detail": "Note pericoronitis, caries on the third molar or adjacent second molar, cyst or lesion association, and patient-reported pain or swelling history.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check for symptoms and pathology indicators"
        },
        {
          "detail": "Treat in-office or refer to oral surgery",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "refer-out",
              "label": "Refer — nerve canal contact/overlap, deep bony impaction, or complex root morphology"
            },
            {
              "goto": "s5",
              "id": "treat-in-office",
              "label": "Treat in-office — favorable angulation, adequate access, low nerve risk"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "title": "Treat in-office or refer to oral surgery"
        },
        {
          "detail": "The treating dentist signs off on the treat-in-office-versus-refer decision before it is acted on, noting the specific nerve/sinus risk factors that drove the call.\n\nWhy: A nerve-proximity referral decision carries license-level clinical judgment and cannot default through without the treating dentist's own sign-off.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the treat-versus-refer decision.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the treat-versus-refer decision",
          "why": "A nerve-proximity referral decision carries license-level clinical judgment and cannot default through without the treating dentist's own sign-off."
        },
        {
          "detail": "Route per the signed-off decision",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "route-refer",
              "label": "Referral confirmed"
            },
            {
              "goto": "s11",
              "id": "route-inoffice",
              "label": "In-office treatment confirmed"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "title": "Route per the signed-off decision"
        },
        {
          "detail": "Compile the panoramic image, assessment notes, and reason for referral; identify a receiving oral surgery office.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the referral package"
        },
        {
          "detail": "Treatment coordinator transmits the referral package and schedules the patient's consult.\n\nRecord: referral sent, destination, and date logged in the chart",
          "id": "s8",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Send referral to oral surgery"
        },
        {
          "detail": "Third molar case referred to oral surgery",
          "id": "s9",
          "kind": "step",
          "title": "Third molar case referred to oral surgery"
        },
        {
          "detail": "Order CBCT or equivalent 3D imaging before finalizing the treat-versus-refer decision when the panoramic shows equivocal nerve-canal proximity; this is a general imaging-escalation step, not tied to any institute-specific protocol.\n\nWhy: A 2D panoramic image alone is not sufficient to finalize a treat-versus-refer call when it shows equivocal signs of nerve-canal contact — this decision should not be made from the pano alone.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Order CBCT/3D imaging to clarify the nerve-canal relationship",
          "why": "A 2D panoramic image alone is not sufficient to finalize a treat-versus-refer call when it shows equivocal signs of nerve-canal contact — this decision should not be made from the pano alone."
        },
        {
          "detail": "Route to simple or surgical extraction protocol based on the case's difficulty score.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the appropriate in-office extraction protocol"
        },
        {
          "detail": "Third molar routed to in-office extraction",
          "id": "s12",
          "kind": "step",
          "title": "Third molar routed to in-office extraction"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Third-molar assessment and treat-versus-refer decision (nerve proximity, impaction) — A panoramic image shows impacted or symptomatic third molars.",
      "title": "Third-molar assessment and treat-versus-refer decision (nerve proximity, impaction)",
      "trigger": "A panoramic image shows impacted or symptomatic third molars",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "osx-005",
      "kind": "clinical",
      "materials": [
        "bone graft material",
        "resorbable or non-resorbable membrane",
        "sutures",
        "curette",
        "syringe or carrier for graft material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the patient consented specifically to placement of graft material and, if used, a membrane, with its own risks (graft failure, infection, exposure) explained.\n\nWhy: Grafting is an additional procedure with its own risk profile and, often, its own fee — it needs its own explicit consent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent covers grafting, separate from the extraction consent.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent covers grafting, separate from the extraction consent",
          "why": "Grafting is an additional procedure with its own risk profile and, often, its own fee — it needs its own explicit consent."
        },
        {
          "detail": "Deliver the tooth atraumatically, preserving as much buccal and lingual bone wall as possible.\n\nWhy: Preserving the socket walls is what makes preservation grafting effective — an atraumatic extraction technique matters more here than in a routine extraction.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the extraction per the simple or surgical protocol",
          "why": "Preserving the socket walls is what makes preservation grafting effective — an atraumatic extraction technique matters more here than in a routine extraction."
        },
        {
          "detail": "Remove all granulation tissue and any residual periodontal ligament remnants; confirm the socket walls are intact.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Debride and curette the socket thoroughly"
        },
        {
          "detail": "Are the socket walls intact enough to graft?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "walls-intact",
              "label": "Walls intact — proceed with graft placement"
            },
            {
              "goto": "s9",
              "id": "walls-compromised",
              "label": "Significant wall loss — refer for advanced ridge augmentation"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "title": "Are the socket walls intact enough to graft?"
        },
        {
          "detail": "Fill the socket to the level of the surrounding bone crest with the selected graft material, avoiding overpacking.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Place bone graft material into the socket"
        },
        {
          "detail": "Cover the graft with a membrane if the technique calls for one, and secure with sutures for primary or partial soft-tissue coverage.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Place a membrane and suture"
        },
        {
          "detail": "Enter the graft material, membrane used, wall integrity assessment, and planned implant timeline into the chart note.\n\nRecord: graft material and lot/category, membrane used, wall integrity assessment, and planned implant timeline, entered in the chart note",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the grafting procedure"
        },
        {
          "detail": "Socket preservation graft complete",
          "id": "s8",
          "kind": "step",
          "title": "Socket preservation graft complete"
        },
        {
          "detail": "A socket with major wall loss needs a technique beyond routine socket preservation; route to the treat-versus-refer pathway.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to oral surgery for advanced ridge augmentation"
        },
        {
          "detail": "Case referred for advanced ridge augmentation",
          "id": "s10",
          "kind": "step",
          "title": "Case referred for advanced ridge augmentation"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Socket preservation grafting at extraction for a future implant — The extraction site is planned for an implant and ridge preservation is chosen.",
      "title": "Socket preservation grafting at extraction for a future implant",
      "trigger": "The extraction site is planned for an implant and ridge preservation is chosen",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        },
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "osx-006",
      "kind": "clinical",
      "materials": [
        "gauze",
        "written post-op instruction sheet",
        "ice pack",
        "follow-up call log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Place a folded gauze pad directly over the socket and have the patient bite down firmly for at least 20-30 minutes before checking.\n\nWhy: Direct sustained pressure is the first-line, lowest-risk way to control normal post-extraction bleeding.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Achieve hemostasis with direct pressure",
          "why": "Direct sustained pressure is the first-line, lowest-risk way to control normal post-extraction bleeding."
        },
        {
          "detail": "Bleeding controlled after pressure?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "controlled",
              "label": "Bleeding controlled — proceed to dismissal"
            },
            {
              "goto": "s7",
              "id": "not-controlled",
              "label": "Still bleeding actively"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Bleeding controlled after pressure?"
        },
        {
          "detail": "Walk through the instruction sheet aloud: bite pressure duration, ice for swelling, no rinsing/spitting/straws for the first 24 hours, soft diet, when to resume normal brushing, and signs that warrant a call (heavy bleeding, fever, worsening pain after day 3).\n\nWhy: Reading it aloud in addition to handing over the sheet improves retention when patients are still numb and anxious.\n\nRecord: written instructions given and reviewed, noted in the chart",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Review written post-op instructions with the patient",
          "why": "Reading it aloud in addition to handing over the sheet improves retention when patients are still numb and anxious."
        },
        {
          "detail": "The dentist reviews and signs off on any prescribed antibiotic or pain medication before it is finalized, reinforcing non-opioid options first per current public prescribing guidance where clinically appropriate.\n\nWhy: Prescribing decisions are the treating dentist's own consequential act and are never finalized by delegated staff.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the medication and pain-management plan.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the medication and pain-management plan",
          "why": "Prescribing decisions are the treating dentist's own consequential act and are never finalized by delegated staff."
        },
        {
          "detail": "Add the patient to the follow-up call list with the extraction date and any risk flags (surgical case, medical risk factors) for a courtesy check-in call.\n\nRecord: follow-up call scheduled in the call log",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log a follow-up call for 24-48 hours later"
        },
        {
          "detail": "Patient dismissed with instructions and follow-up scheduled",
          "id": "s6",
          "kind": "step",
          "title": "Patient dismissed with instructions and follow-up scheduled"
        },
        {
          "detail": "Do not dismiss a patient with uncontrolled bleeding; move to the dedicated post-extraction bleeding protocol.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the persistent-bleeding protocol"
        },
        {
          "detail": "Case continues under the persistent-bleeding protocol",
          "id": "s8",
          "kind": "step",
          "title": "Case continues under the persistent-bleeding protocol"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Post-extraction hemostasis, written instructions and follow-up call setup — The extraction is complete and the patient is about to be dismissed.",
      "title": "Post-extraction hemostasis, written instructions and follow-up call setup",
      "trigger": "The extraction is complete and the patient is about to be dismissed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osx-007",
      "kind": "clinical",
      "materials": [
        "gauze",
        "hemostatic agent (e.g. absorbable gelatin or oxidized cellulose)",
        "suture kit",
        "blood pressure cuff"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the patient reports soaking through multiple gauze pads per hour, feels faint, is difficult to rouse, or bleeding is accompanied by chest pain or difficulty breathing, call 911/EMS immediately before anything else; do not attempt to manage a life-threatening bleed by phone.\n\nWhy: Rule-based emergency triage runs before any other step or any AI-assisted routing — severity determines whether this becomes a same-day office visit or a 911 call.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Triage severity — call 911/EMS first if life-threatening.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Triage severity — call 911/EMS first if life-threatening",
          "why": "Rule-based emergency triage runs before any other step or any AI-assisted routing — severity determines whether this becomes a same-day office visit or a 911 call."
        },
        {
          "detail": "Is this a life-threatening bleed?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "not-life-threatening",
              "label": "Steady oozing, patient stable, no faintness — bring in for chairside management"
            },
            {
              "goto": "s10",
              "id": "life-threatening",
              "label": "Signs above present — EMS already called"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Is this a life-threatening bleed?"
        },
        {
          "detail": "Schedule the patient for immediate same-day evaluation; have them bite firmly on a moistened gauze pad en route if instructed by phone.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Bring the patient in for chairside evaluation"
        },
        {
          "detail": "Take blood pressure and pulse; ask about anticoagulant medications, missed doses, aspirin use, and any known bleeding disorder.\n\nWhy: Vitals and medication history determine whether local measures alone are appropriate or medical consultation is needed.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Check vital signs and review anticoagulant/bleeding-disorder history",
          "why": "Vitals and medication history determine whether local measures alone are appropriate or medical consultation is needed."
        },
        {
          "detail": "Remove the existing clot debris, place a hemostatic agent into the socket, and apply firm direct pressure with gauze for 20-30 minutes.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Apply local hemostatic measures"
        },
        {
          "detail": "Bleeding controlled after local measures?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "resolved",
              "label": "Controlled — proceed to discharge with revised instructions"
            },
            {
              "goto": "s12",
              "id": "still-bleeding",
              "label": "Still bleeding after local measures"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "title": "Bleeding controlled after local measures?"
        },
        {
          "detail": "If a discrete bleeding vessel or flap edge is identified, place a figure-eight or simple suture to achieve mechanical hemostasis.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Place a suture if a bleeding point is identified"
        },
        {
          "detail": "Enter the presentation time, vitals, measures taken, outcome, and revised post-op instructions into the chart note.\n\nRecord: time of presentation, vitals, measures taken, outcome, and revised post-op instructions given, entered in the chart note",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the event and revised instructions"
        },
        {
          "detail": "Bleeding resolved and patient discharged with revised instructions",
          "id": "s9",
          "kind": "step",
          "title": "Bleeding resolved and patient discharged with revised instructions"
        },
        {
          "detail": "Provide EMS with the procedure performed, time of extraction, and any relevant medical history (anticoagulant use, bleeding disorder) as they take over care.\n\nRecord: EMS called, time, and handoff summary logged in the chart",
          "id": "s10",
          "kind": "step",
          "role": "ems",
          "title": "Hand off to EMS on arrival"
        },
        {
          "detail": "Care transferred to EMS",
          "id": "s11",
          "kind": "step",
          "title": "Care transferred to EMS"
        },
        {
          "detail": "If bleeding persists despite hemostatic agent, pressure, and any indicated suturing, the dentist arranges physician consultation or directs the patient to the emergency department rather than repeating ineffective local measures.\n\nWhy: Persistent bleeding after appropriate local measures may indicate an underlying medical issue outside the scope of chairside dental management.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate to medical consultation or ED if local measures fail.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "dentist",
          "title": "Escalate to medical consultation or ED if local measures fail",
          "why": "Persistent bleeding after appropriate local measures may indicate an underlying medical issue outside the scope of chairside dental management."
        },
        {
          "detail": "Patient escalated to medical consultation or emergency department",
          "id": "s13",
          "kind": "step",
          "title": "Patient escalated to medical consultation or emergency department"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Post-extraction bleeding that will not stop — local measures to escalation — A patient calls or returns with continued bleeding hours after extraction, or bleeding will not stop chairside despite pressure.",
      "title": "Post-extraction bleeding that will not stop — local measures to escalation",
      "trigger": "A patient calls or returns with continued bleeding hours after extraction, or bleeding will not stop chairside despite pressure",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
          "url": "https://www.aaoms.org/"
        },
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "osx-008",
      "kind": "clinical",
      "materials": [
        "irrigation syringe with saline",
        "medicated dressing (e.g. eugenol-based dry socket paste)",
        "gauze",
        "mirror and explorer"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Examine the socket for a partially or fully lost clot with exposed bone, characteristic foul odor, and pain onset timing of roughly two to four days post-extraction; rule out infection with swelling/fever or a retained root fragment.\n\nWhy: Dry socket has a distinct presentation from infection or a retained fragment, and each needs a different management path.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the diagnosis is dry socket, not another cause of pain",
          "why": "Dry socket has a distinct presentation from infection or a retained fragment, and each needs a different management path."
        },
        {
          "detail": "Confirmed dry socket or another cause?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "confirmed",
              "label": "Confirmed dry socket — proceed to irrigation and dressing"
            },
            {
              "goto": "s9",
              "id": "other-cause",
              "label": "Signs of infection, swelling, or suspected retained fragment"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Confirmed dry socket or another cause?"
        },
        {
          "detail": "The dentist confirms the dry-socket diagnosis and the plan to irrigate and dress the socket before the assistant proceeds with materials setup.\n\nWhy: Placing a medicated dressing is a treatment act that requires the treating dentist's own confirmed diagnosis, not staff judgment alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before dressing placement.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before dressing placement",
          "why": "Placing a medicated dressing is a treatment act that requires the treating dentist's own confirmed diagnosis, not staff judgment alone."
        },
        {
          "detail": "Gently irrigate to remove debris and food particles without disturbing surrounding bone.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Irrigate the socket with saline"
        },
        {
          "detail": "Pack a medicated dry-socket dressing loosely into the socket to provide symptomatic relief; avoid tight packing.\n\nWhy: The dressing is for pain relief, not to promote healing directly — packing too tightly can trap debris and delay natural healing.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Place a medicated dressing into the socket",
          "why": "The dressing is for pain relief, not to promote healing directly — packing too tightly can trap debris and delay natural healing."
        },
        {
          "detail": "Explain that pain should improve within 24-48 hours, review home care (gentle rinsing, avoiding the area), and schedule a follow-up visit to change or remove the dressing.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Advise the patient and schedule dressing change"
        },
        {
          "detail": "Enter the confirmed diagnosis, irrigation and dressing performed, and follow-up appointment into the chart note.\n\nRecord: diagnosis confirmed, irrigation and dressing performed, and follow-up appointment scheduled, entered in the chart note",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the visit"
        },
        {
          "detail": "Dry socket dressed and follow-up scheduled",
          "id": "s8",
          "kind": "step",
          "title": "Dry socket dressed and follow-up scheduled"
        },
        {
          "detail": "Infection, swelling, or a suspected retained root fragment is managed under its own protocol rather than as simple dry socket.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the appropriate protocol for the actual finding"
        },
        {
          "detail": "Case redirected to the appropriate protocol",
          "id": "s10",
          "kind": "step",
          "title": "Case redirected to the appropriate protocol"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Dry socket (alveolar osteitis) diagnosis and dressing — Severe throbbing pain two to four days after extraction with an empty socket.",
      "title": "Dry socket (alveolar osteitis) diagnosis and dressing",
      "trigger": "Severe throbbing pain two to four days after extraction with an empty socket",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)",
          "source": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)"
        },
        {
          "kind": "open_standard",
          "label": "AAOMS White Paper on Third Molar Data + JADA 'The indications for third-molar extractions' — third-molar complication management only",
          "repaired": {
            "action": "reduce",
            "evidence": "'Third-molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed'; pericoronitis is described as 'a typical inflammatory pathology of the impacted or partially impacted third molar... accepted treatment regimens including antibiotic therapy coupled with surgical intervention'; oroantral communication is described as 'an unnatural communication of the maxillary sinus with the oral cavity, often resulting from dental extractions... In case of an infected oroantral communication or fistula, priority rests on treating the infection first and followed by surgical repair.' (search results, AAOMS/JADA/PMC sources on third-molar guidelines.)",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
              "url": null
            }
          },
          "source": "AAOMS White Paper on Third Molar Data (aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf); JADA, 'The indications for third-molar extractions' (jada.ada.org/article/S0002-8177(14)60117-3/fulltext). Scope: osx-009 (fractured root tip), osx-010 (oroantral communication), osx-011 (tooth/fragment displaced into sinus), osx-014 (post-surgical infection/antibiotics), osx-016 (pericoronitis) only — does NOT reach osx-012 (soft-tissue biopsy submission chain), which is an oral-pathology specimen-handling matter, not a third-molar guideline topic.",
          "url": "https://aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent: risk-based retrieve-or-leave decision framework for a fractured root tip — not tied to any institute protocol",
          "source": "Generic functional equivalent: risk-based retrieve-or-leave decision framework for a fractured root tip — not tied to any institute protocol"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "osx-009",
      "kind": "clinical",
      "materials": [
        "periapical/panoramic radiograph",
        "surgical extraction tray",
        "irrigation and suction",
        "chart/consent module"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "specialist-referral",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pause the extraction, irrigate and suction the socket, and take a periapical radiograph (or use the existing panoramic) to locate the fragment's size, depth and relationship to the sinus or nerve canal.\n\nWhy: A radiograph before further instrumentation prevents chasing a fragment blind, which is how small complications become large ones.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Stop, irrigate the field and assess the fragment",
          "why": "A radiograph before further instrumentation prevents chasing a fragment blind, which is how small complications become large ones."
        },
        {
          "detail": "Weigh fragment size against the office's configured retrieval threshold (commonly set around 3-4mm when there is no infection and no sinus/nerve proximity — see method_editable_fields), depth, proximity to the sinus floor or inferior alveolar canal, and infection status.\n\nWhy: Aggressive retrieval of a small, deep, uninfected fragment risks more surgical trauma than leaving it; the decision belongs to a licensed clinician weighing that trade-off, not a default action.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "leave",
              "label": "Low-risk fragment — plan to leave and monitor"
            },
            {
              "goto": "s9",
              "id": "attempt",
              "label": "Accessible fragment — attempt limited retrieval"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the fragment small, deep, and low-risk to retrieve versus leave?",
          "why": "Aggressive retrieval of a small, deep, uninfected fragment risks more surgical trauma than leaving it; the decision belongs to a licensed clinician weighing that trade-off, not a default action."
        },
        {
          "detail": "Record fragment size/location on the radiograph, the clinical rationale for leaving it in place, and the plan (monitor vs. specialist referral) in the operative note.\n\nRecord: Operative note: fragment description, radiograph reference, retrieve-vs-leave rationale, monitoring or referral plan.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Document the retained-fragment decision and rationale"
        },
        {
          "detail": "Before the patient leaves, the dentist personally explains what happened, what was done, and the plan (monitor with a follow-up radiograph, or referral). Answer questions and confirm understanding.\n\nWhy: Prompt, direct disclosure of an adverse or unexpected surgical event is expected practice and supports the patient's ongoing informed consent — this is not optional paperwork.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the finding to the patient before dismissal.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Disclose the finding to the patient before dismissal",
          "why": "Prompt, direct disclosure of an adverse or unexpected surgical event is expected practice and supports the patient's ongoing informed consent — this is not optional paperwork."
        },
        {
          "detail": "Does the fragment's location or the patient's risk profile warrant a specialist referral?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "monitor",
              "label": "Monitor in-house with a follow-up radiograph"
            },
            {
              "goto": "s12",
              "id": "refer",
              "label": "Refer to a specialist for evaluation"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the fragment's location or the patient's risk profile warrant a specialist referral?"
        },
        {
          "detail": "Book a follow-up visit to re-image the site and confirm the fragment remains asymptomatic and stable.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up radiograph at the recall interval"
        },
        {
          "detail": "Record the case in the practice's complication log for the monthly quality review, generic front-office record-keeping.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident for the monthly complication review"
        },
        {
          "detail": "Root-tip decision made, disclosed and documented",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Root-tip decision made, disclosed and documented"
        },
        {
          "detail": "Make a bounded number of retrieval attempts using root tip picks or minimal bone removal; stop if the attempt is enlarging the surgical site without progress.\n\nWhy: An open-ended chase for a small fragment is the classic path to an oroantral communication or nerve injury (see osx-010, osx-015).",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Attempt a limited, time-boxed retrieval",
          "why": "An open-ended chase for a small fragment is the classic path to an oroantral communication or nerve injury (see osx-010, osx-015)."
        },
        {
          "detail": "Was the fragment retrieved?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "retrieved",
              "label": "Fragment retrieved"
            },
            {
              "goto": "s3",
              "id": "not-retrieved",
              "label": "Still not retrieved — stop and leave"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Was the fragment retrieved?"
        },
        {
          "detail": "Confirm hemostasis, place sutures if indicated, and proceed to standard post-extraction instructions.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Complete extraction and socket closure"
        },
        {
          "detail": "Send the radiograph, operative note and disclosure summary to the specialist referral office and confirm the patient has an appointment.",
          "id": "s12",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Hand off to the specialist referral with imaging and notes"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Fractured root tip — retrieve or leave decision and disclosure — A root tip breaks during extraction.",
      "title": "Fractured root tip — retrieve or leave decision and disclosure",
      "trigger": "A root tip breaks during extraction",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)",
          "source": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)"
        },
        {
          "kind": "open_standard",
          "label": "AAOMS White Paper on Third Molar Data + JADA 'The indications for third-molar extractions' — third-molar complication management only",
          "repaired": {
            "action": "reduce",
            "evidence": "'Third-molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed'; pericoronitis is described as 'a typical inflammatory pathology of the impacted or partially impacted third molar... accepted treatment regimens including antibiotic therapy coupled with surgical intervention'; oroantral communication is described as 'an unnatural communication of the maxillary sinus with the oral cavity, often resulting from dental extractions... In case of an infected oroantral communication or fistula, priority rests on treating the infection first and followed by surgical repair.' (search results, AAOMS/JADA/PMC sources on third-molar guidelines.)",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
              "url": null
            }
          },
          "source": "AAOMS White Paper on Third Molar Data (aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf); JADA, 'The indications for third-molar extractions' (jada.ada.org/article/S0002-8177(14)60117-3/fulltext). Scope: osx-009 (fractured root tip), osx-010 (oroantral communication), osx-011 (tooth/fragment displaced into sinus), osx-014 (post-surgical infection/antibiotics), osx-016 (pericoronitis) only — does NOT reach osx-012 (soft-tissue biopsy submission chain), which is an oral-pathology specimen-handling matter, not a third-molar guideline topic.",
          "url": "https://aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": ": size-based oroantral communication triage (small spontaneous closure vs. suture vs. specialist flap) — not tied to any institute protocol — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: size-based oroantral communication triage (small spontaneous closure vs. suture vs. specialist flap) — not tied to any institute protocol"
          },
          "source": ": size-based oroantral communication triage (small spontaneous closure vs. suture vs. specialist flap) — not tied to any institute protocol — Practice policy — no published authority governs this step."
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "osx-010",
      "kind": "clinical",
      "materials": [
        "periapical radiograph",
        "suture kit",
        "nasal-blow test materials (none required, patient instructed)",
        "antibiotic and decongestant prescription pad"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "specialist-referral",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "After a maxillary premolar or molar extraction, gently check for air bubbles at the socket, ask the patient to attempt a very gentle nasal blow with the nose pinched (a positive result is a red flag), and inspect for a visible opening or fluid reflux.\n\nWhy: Root tips of maxillary posterior teeth often approximate the sinus floor; a missed communication left untreated can develop into a chronic sinus tract or sinusitis.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Screen every maxillary posterior extraction site for a communication",
          "why": "Root tips of maxillary posterior teeth often approximate the sinus floor; a missed communication left untreated can develop into a chronic sinus tract or sinusitis."
        },
        {
          "detail": "Confirm size by direct visualization and the radiograph relationship to the sinus floor.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "none",
              "label": "No communication found"
            },
            {
              "goto": "s5",
              "id": "small",
              "label": "Small communication (under the office's configured size threshold — commonly ~2mm)"
            },
            {
              "goto": "s10",
              "id": "large",
              "label": "Larger communication or persistent opening"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a communication present, and how large?"
        },
        {
          "detail": "Proceed with the practice's standard post-extraction hemostasis and instructions (osx-006).",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Give standard post-extraction instructions"
        },
        {
          "detail": "Oroantral communication screened, managed, disclosed and documented",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Oroantral communication screened, managed, disclosed and documented"
        },
        {
          "detail": "For a small communication expected to close on its own with clot formation, give explicit sinus precautions: no nose blowing, no straws, no smoking, sneeze with mouth open, avoid drinking through a straw for the healing period stated by the office.\n\nWhy: Small communications commonly close spontaneously if the clot is protected; violating sinus precautions is the leading cause of a small communication becoming persistent.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Plan for spontaneous closure with sinus precautions",
          "why": "Small communications commonly close spontaneously if the clot is protected; violating sinus precautions is the leading cause of a small communication becoming persistent."
        },
        {
          "detail": "Before the patient leaves, the dentist personally explains the communication, what was done (spontaneous-closure plan, suture, or referral), sinus precautions, and warning signs to call about (persistent fluid from the nose, worsening pain, sinus pressure).\n\nWhy: Timely disclosure of an adverse or unexpected surgical event is expected practice, and the patient must understand precautions that materially affect healing.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the finding and precautions to the patient before dismissal.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Disclose the finding and precautions to the patient before dismissal",
          "why": "Timely disclosure of an adverse or unexpected surgical event is expected practice, and the patient must understand precautions that materially affect healing."
        },
        {
          "detail": "Per the office's clinical judgment and current openly published guidance, consider an antibiotic and a decongestant to reduce sinusitis risk while the communication heals.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe antibiotics and/or decongestant if indicated"
        },
        {
          "detail": "Book a follow-up appointment within the office's standard interval to re-check the site for closure and resolution of symptoms.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up visit to confirm closure"
        },
        {
          "detail": "Record the case in the practice's complication log for the monthly quality review, generic front-office record-keeping.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident for the monthly complication review"
        },
        {
          "detail": "A larger opening beyond simple suture closure, or one accompanied by sinus lining tear, calls for a specialist flap procedure rather than an in-house attempt.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "suture",
              "label": "Close with figure-eight suture in-house"
            },
            {
              "goto": "s12",
              "id": "refer",
              "label": "Refer for specialist flap closure"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Close with figure-eight suture in-house, or refer for flap closure?"
        },
        {
          "detail": "Suture the socket margins to approximate soft tissue over the opening; re-check for air passage after placement.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Place a figure-eight suture and confirm closure"
        },
        {
          "detail": "Send the radiograph, operative note describing the communication size and any temporary closure attempted, and contact the specialist referral office to expedite the appointment.\n\nWhy: A sinus communication left open beyond in-house closure capability risks chronic oroantral fistula formation the longer it is untreated.",
          "id": "s12",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Hand off to the specialist referral with imaging and notes",
          "why": "A sinus communication left open beyond in-house closure capability risks chronic oroantral fistula formation the longer it is untreated."
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Oroantral communication recognition and closure — Air bubbles, fluid reflux or a visible opening after a maxillary posterior extraction.",
      "title": "Oroantral communication recognition and closure",
      "trigger": "Air bubbles, fluid reflux or a visible opening after a maxillary posterior extraction",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)",
          "source": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)"
        },
        {
          "kind": "open_standard",
          "label": "AAOMS White Paper on Third Molar Data + JADA 'The indications for third-molar extractions' — third-molar complication management only",
          "repaired": {
            "action": "reduce",
            "evidence": "'Third-molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed'; pericoronitis is described as 'a typical inflammatory pathology of the impacted or partially impacted third molar... accepted treatment regimens including antibiotic therapy coupled with surgical intervention'; oroantral communication is described as 'an unnatural communication of the maxillary sinus with the oral cavity, often resulting from dental extractions... In case of an infected oroantral communication or fistula, priority rests on treating the infection first and followed by surgical repair.' (search results, AAOMS/JADA/PMC sources on third-molar guidelines.)",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
              "url": null
            }
          },
          "source": "AAOMS White Paper on Third Molar Data (aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf); JADA, 'The indications for third-molar extractions' (jada.ada.org/article/S0002-8177(14)60117-3/fulltext). Scope: osx-009 (fractured root tip), osx-010 (oroantral communication), osx-011 (tooth/fragment displaced into sinus), osx-014 (post-surgical infection/antibiotics), osx-016 (pericoronitis) only — does NOT reach osx-012 (soft-tissue biopsy submission chain), which is an oral-pathology specimen-handling matter, not a third-molar guideline topic.",
          "url": "https://aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": ": stop-image-refer protocol for a displaced tooth/fragment into the sinus or a fascial space — not tied to any institute protocol — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: stop-image-refer protocol for a displaced tooth/fragment into the sinus or a fascial space — not tied to any institute protocol"
          },
          "source": ": stop-image-refer protocol for a displaced tooth/fragment into the sinus or a fascial space — not tied to any institute protocol — Practice policy — no published authority governs this step."
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osx-011",
      "kind": "clinical",
      "materials": [
        "periapical/panoramic radiograph",
        "phone for specialist/ER coordination",
        "chart/consent module"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "specialist-referral",
        "front-desk",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Immediately stop probing for the fragment. Check the patient for any sign of airway compromise: difficulty breathing, stridor, inability to swallow, or a sensation of something in the throat. If any airway symptom is present, call 911 immediately and begin basic life support per office training while awaiting EMS.\n\nWhy: A displaced fragment near the airway is the one branch of this incident that is immediately life-threatening; every other consideration is secondary to ruling this out first.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop instrumentation and check for airway or breathing compromise.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Stop instrumentation and check for airway or breathing compromise",
          "why": "A displaced fragment near the airway is the one branch of this incident that is immediately life-threatening; every other consideration is secondary to ruling this out first."
        },
        {
          "detail": "Is there any airway or swallowing symptom?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "compromised",
              "label": "Airway symptom present"
            },
            {
              "goto": "s6",
              "id": "clear",
              "label": "No airway symptom — patient stable and breathing normally"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is there any airway or swallowing symptom?"
        },
        {
          "detail": "Call 911, state the nature of the emergency (displaced dental fragment, possible airway compromise), stay on the line, and keep the patient upright and calm. Do not attempt to retrieve the fragment.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Call 911 and stay with the patient until EMS arrives"
        },
        {
          "detail": "Record the case, including the 911 call if one was made, in the practice's complication log for the monthly quality review, generic front-office record-keeping.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident for the monthly complication review"
        },
        {
          "detail": "Displaced fragment triaged, imaged, referred, disclosed and documented",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Displaced fragment triaged, imaged, referred, disclosed and documented"
        },
        {
          "detail": "Take a radiograph (panoramic or CBCT if available) to determine whether the fragment is in the maxillary sinus, has migrated into a fascial space (e.g. submandibular, sublingual, infratemporal), or is elsewhere.\n\nWhy: The retrieval approach and referral urgency differ by location — a sinus fragment and a fascial-space fragment are not managed the same way.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Image to locate the fragment",
          "why": "The retrieval approach and referral urgency differ by location — a sinus fragment and a fascial-space fragment are not managed the same way."
        },
        {
          "detail": "Where is the fragment, and does it need same-day referral?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "sinus-small",
              "label": "Small fragment in an accessible sinus location, patient stable"
            },
            {
              "goto": "s11",
              "id": "fascial-space",
              "label": "Fragment in a fascial space or not clearly located"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Where is the fragment, and does it need same-day referral?"
        },
        {
          "detail": "Send the radiograph and operative note describing the displacement and location, and confirm a prompt specialist appointment.",
          "id": "s8",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Hand off to the specialist referral with imaging and notes"
        },
        {
          "detail": "Before dismissal, the dentist personally explains what happened, the imaging findings, the referral plan, and warning signs to seek immediate care for (breathing difficulty, worsening swelling, fever).\n\nWhy: Prompt, direct disclosure of an adverse or unexpected surgical event is expected practice, and the patient must understand when to seek emergency care after leaving.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the incident to the patient before they leave the office.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Disclose the incident to the patient before they leave the office",
          "why": "Prompt, direct disclosure of an adverse or unexpected surgical event is expected practice, and the patient must understand when to seek emergency care after leaving."
        },
        {
          "detail": "Call the patient later the same day to confirm the specialist/ER appointment was kept and no new symptoms have developed.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Front desk places a same-day follow-up call"
        },
        {
          "detail": "Contact an oral surgeon or the nearest emergency department directly by phone, describe the imaging findings, and arrange transport or an immediate appointment. Do not send the patient home to 'wait and see.'\n\nWhy: A fragment in a fascial space can migrate further or seed an infection; same-day evaluation is the safe default when location is uncertain.",
          "id": "s11",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Arrange same-day urgent specialist or ER evaluation",
          "why": "A fragment in a fascial space can migrate further or seed an infection; same-day evaluation is the safe default when location is uncertain."
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Tooth or fragment displaced into the sinus or a fascial space — A tooth or root disappears into the sinus or submandibular space during extraction.",
      "title": "Tooth or fragment displaced into the sinus or a fascial space",
      "trigger": "A tooth or root disappears into the sinus or submandibular space during extraction",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)",
          "source": "OSHA 29 CFR 1910.1030 (sharps, bloodborne exposure)"
        },
        {
          "kind": "open_standard",
          "label": "AAOMS White Paper on Third Molar Data + JADA 'The indications for third-molar extractions' — third-molar complication management only",
          "repaired": {
            "action": "reduce",
            "evidence": "'Third-molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed'; pericoronitis is described as 'a typical inflammatory pathology of the impacted or partially impacted third molar... accepted treatment regimens including antibiotic therapy coupled with surgical intervention'; oroantral communication is described as 'an unnatural communication of the maxillary sinus with the oral cavity, often resulting from dental extractions... In case of an infected oroantral communication or fistula, priority rests on treating the infection first and followed by surgical repair.' (search results, AAOMS/JADA/PMC sources on third-molar guidelines.)",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
              "url": null
            }
          },
          "source": "AAOMS White Paper on Third Molar Data (aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf); JADA, 'The indications for third-molar extractions' (jada.ada.org/article/S0002-8177(14)60117-3/fulltext). Scope: osx-009 (fractured root tip), osx-010 (oroantral communication), osx-011 (tooth/fragment displaced into sinus), osx-014 (post-surgical infection/antibiotics), osx-016 (pericoronitis) only — does NOT reach osx-012 (soft-tissue biopsy submission chain), which is an oral-pathology specimen-handling matter, not a third-molar guideline topic.",
          "url": "https://aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "CLIA (42 CFR 493) requisition and specimen labeling requirements for laboratory submission",
          "source": "CLIA (42 CFR 493) requisition and specimen labeling requirements for laboratory submission"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent: chain-of-custody specimen labeling and pathology submission workflow — not tied to any laboratory vendor",
          "source": "Generic functional equivalent: chain-of-custody specimen labeling and pathology submission workflow — not tied to any laboratory vendor"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "osx-012",
      "kind": "clinical",
      "materials": [
        "biopsy tray (scalpel or punch)",
        "formalin specimen container and pathology requisition form",
        "consent form",
        "camera for pre-biopsy documentation"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "specialist-referral",
        "front-desk",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Record the lesion's location, size, color, surface texture, duration, and any patient-reported symptoms; photograph it with a size reference if available.\n\nWhy: Pre-biopsy documentation gives the pathology report a clinical context and creates a baseline if the site needs re-evaluation.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Document the lesion before biopsy",
          "why": "Pre-biopsy documentation gives the pathology report a clinical context and creates a baseline if the site needs re-evaluation."
        },
        {
          "detail": "Consider lesion location, size, accessibility, and the dentist's comfort and training for the specific technique required.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "inhouse",
              "label": "Biopsy in-house"
            },
            {
              "goto": "s10",
              "id": "refer",
              "label": "Refer to a specialist for biopsy"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Perform the biopsy in-house, or refer to a specialist?"
        },
        {
          "detail": "Explain the procedure (incisional vs excisional), risks (bleeding, scarring, discomfort), and that a laboratory will examine the tissue; obtain signed consent before proceeding.\n\nWhy: A biopsy is an invasive procedure whose result may carry serious news; consent must be informed and on file before any tissue is removed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain informed consent for biopsy before the procedure.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain informed consent for biopsy before the procedure",
          "why": "A biopsy is an invasive procedure whose result may carry serious news; consent must be informed and on file before any tissue is removed."
        },
        {
          "detail": "Take the incisional or excisional sample per the chosen technique, place the specimen immediately into fixative (formalin), and achieve hemostasis at the site with sutures if needed.\n\nWhy: Placing the specimen into fixative immediately preserves tissue architecture the pathologist needs for an accurate read.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the biopsy and achieve hemostasis",
          "why": "Placing the specimen into fixative immediately preserves tissue architecture the pathologist needs for an accurate read."
        },
        {
          "detail": "Confirm the specimen container is labeled with the patient's identifiers matching the chart, and complete the pathology requisition form with clinical history, lesion description, location, and the dentist's differential impression.\n\nWhy: A mislabeled specimen or an incomplete requisition is the most common cause of a delayed or rejected pathology submission.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Label the specimen and complete the pathology requisition",
          "why": "A mislabeled specimen or an incomplete requisition is the most common cause of a delayed or rejected pathology submission."
        },
        {
          "detail": "Package and send the labeled specimen and completed requisition to the pathology laboratory per the office's standard courier or mail process; log the submission date.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the specimen and requisition to the pathology laboratory"
        },
        {
          "detail": "Provide post-operative care instructions and tell the patient the expected timeframe for the pathology report and how the office will contact them (see osx-013).",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-biopsy instructions and set the recall expectation"
        },
        {
          "detail": "Enter the biopsy and submission date into the practice's pathology tracking log so an overdue result is caught (see osx-017), generic front-office record-keeping.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the biopsy for tracking against overdue results"
        },
        {
          "detail": "Biopsy performed or referred, specimen submitted, tracking started",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Biopsy performed or referred, specimen submitted, tracking started"
        },
        {
          "detail": "Send the lesion photograph and clinical description to the specialist referral office and confirm the patient has a biopsy appointment scheduled.",
          "id": "s10",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Hand off to the specialist referral with lesion documentation"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Soft-tissue biopsy (incisional or excisional) with pathology submission chain — A lesion persists past two weeks or looks suspicious at screening.",
      "title": "Soft-tissue biopsy (incisional or excisional) with pathology submission chain",
      "trigger": "A lesion persists past two weeks or looks suspicious at screening",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "CLIA (42 CFR 493) results reporting to the ordering provider",
          "source": "CLIA (42 CFR 493) results reporting to the ordering provider"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.524 right of access to test results",
          "source": "HIPAA 45 CFR 164.524 right of access to test results",
          "url": "https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": ": dentist-reviews-before-patient-is-told notification workflow — not tied to any laboratory or portal vendor — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: dentist-reviews-before-patient-is-told notification workflow — not tied to any laboratory or portal vendor"
          },
          "source": ": dentist-reviews-before-patient-is-told notification workflow — not tied to any laboratory or portal vendor — Practice policy — no published authority governs this step."
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "osx-013",
      "kind": "clinical",
      "materials": [
        "pathology report",
        "chart/practice management system",
        "phone for patient notification"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "patient",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Front desk confirms the report has arrived, matches it to the correct patient chart, and marks the tracking log entry as received.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive and log the pathology report"
        },
        {
          "detail": "The dentist personally reads the full pathology report — diagnosis, margins if excisional, and any recommendation — before front desk or any staff member contacts the patient.\n\nWhy: A patient must never learn a pathology result, especially a serious one, from someone who has not reviewed it with the dentist's clinical context; this is the core safeguard of this protocol.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews the report before any patient contact.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews the report before any patient contact",
          "why": "A patient must never learn a pathology result, especially a serious one, from someone who has not reviewed it with the dentist's clinical context; this is the core safeguard of this protocol."
        },
        {
          "detail": "Is the finding benign/routine, or does it require urgent action?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "benign",
              "label": "Benign or routine finding"
            },
            {
              "goto": "s10",
              "id": "urgent",
              "label": "Malignant, atypical, or otherwise urgent finding"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the finding benign/routine, or does it require urgent action?"
        },
        {
          "detail": "Front desk schedules the dentist's call to the patient within the office's standard notification window for benign findings.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a notification call within the target window"
        },
        {
          "detail": "Explain the diagnosis in plain language, what it means, and the next step (routine follow-up, referral for treatment, or further testing). Answer questions.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Deliver the result and the plan to the patient"
        },
        {
          "detail": "Does the finding require a specialist referral for treatment or further evaluation?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-referral",
              "label": "No referral needed — routine follow-up only"
            },
            {
              "goto": "s11",
              "id": "referral",
              "label": "Referral needed"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the finding require a specialist referral for treatment or further evaluation?"
        },
        {
          "detail": "Record the date and time of the call, who spoke with the patient, what was discussed, the patient's understanding, and the plan (routine follow-up or referral).\n\nRecord: Chart note: pathology result, notification date/time, conversation summary, plan.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the notification in the chart"
        },
        {
          "detail": "Mark the pathology tracking log entry as closed with the notification date, generic front-office record-keeping.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Close the tracking log entry"
        },
        {
          "detail": "Pathology report reviewed, patient notified and documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Pathology report reviewed, patient notified and documented"
        },
        {
          "detail": "The dentist calls the patient personally, as soon as practical the same day, to discuss the finding directly rather than through a message or portal notification alone.\n\nWhy: Serious diagnoses require direct, prompt, empathetic communication from the treating clinician, not a delayed or delegated message.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Contact the patient directly and promptly for an urgent finding",
          "why": "Serious diagnoses require direct, prompt, empathetic communication from the treating clinician, not a delayed or delegated message."
        },
        {
          "detail": "Send the full pathology report and chart summary to the specialist referral office and confirm the patient has an appointment scheduled.",
          "id": "s11",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Hand off to the specialist referral with the pathology report"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Pathology report receipt, review and patient notification — A biopsy result arrives from the laboratory.",
      "title": "Pathology report receipt, review and patient notification",
      "trigger": "A biopsy result arrives from the laboratory",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOMS White Paper on Third Molar Data + JADA 'The indications for third-molar extractions' — third-molar complication management only",
          "repaired": {
            "action": "reduce",
            "evidence": "'Third-molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed'; pericoronitis is described as 'a typical inflammatory pathology of the impacted or partially impacted third molar... accepted treatment regimens including antibiotic therapy coupled with surgical intervention'; oroantral communication is described as 'an unnatural communication of the maxillary sinus with the oral cavity, often resulting from dental extractions... In case of an infected oroantral communication or fistula, priority rests on treating the infection first and followed by surgical repair.' (search results, AAOMS/JADA/PMC sources on third-molar guidelines.)",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
              "url": null
            }
          },
          "source": "AAOMS White Paper on Third Molar Data (aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf); JADA, 'The indications for third-molar extractions' (jada.ada.org/article/S0002-8177(14)60117-3/fulltext). Scope: osx-009 (fractured root tip), osx-010 (oroantral communication), osx-011 (tooth/fragment displaced into sinus), osx-014 (post-surgical infection/antibiotics), osx-016 (pericoronitis) only — does NOT reach osx-012 (soft-tissue biopsy submission chain), which is an oral-pathology specimen-handling matter, not a third-molar guideline topic.",
          "url": "https://aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf"
        },
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        },
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent: airway-first triage before any antibiotic decision for post-surgical spreading infection — not tied to any institute protocol",
          "source": "Generic functional equivalent: airway-first triage before any antibiotic decision for post-surgical spreading infection — not tied to any institute protocol"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "osx-014",
      "kind": "clinical",
      "materials": [
        "thermometer",
        "phone for 911/specialist coordination",
        "prescription pad",
        "chart/practice management system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "ems",
        "specialist-referral",
        "front-desk",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If the patient reports or presents with difficulty breathing, difficulty swallowing, a muffled voice, drooling they cannot control, or rapidly spreading swelling into the floor of the mouth or neck, call 911 immediately. Do not attempt to manage this in the office or over the phone first.\n\nWhy: Spreading infection into the floor of the mouth or neck (Ludwig's angina pattern) can compromise the airway within hours; this is the single scenario in this protocol where speed to EMS outranks every other step.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 immediately if there is any sign of airway compromise.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Call 911 immediately if there is any sign of airway compromise",
          "why": "Spreading infection into the floor of the mouth or neck (Ludwig's angina pattern) can compromise the airway within hours; this is the single scenario in this protocol where speed to EMS outranks every other step."
        },
        {
          "detail": "Is there any airway red-flag symptom?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "compromised",
              "label": "Airway red flag present"
            },
            {
              "goto": "s6",
              "id": "stable",
              "label": "No airway red flag — localized swelling, patient breathing and swallowing normally"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is there any airway red-flag symptom?"
        },
        {
          "detail": "Call 911 or direct the patient/caregiver to call 911 or go immediately to the nearest emergency department. Front desk keeps the patient on the line if possible and documents the time of the call.",
          "id": "s3",
          "kind": "step",
          "role": "ems",
          "title": "Call 911, direct the patient to the emergency department, and stay in contact"
        },
        {
          "detail": "Record the case, including whether 911 was called, in the practice's complication log for the monthly quality review, generic front-office record-keeping.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the case for the monthly complication and emergency-call review"
        },
        {
          "detail": "Post-surgical infection triaged, treated or referred, disclosed and documented",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Post-surgical infection triaged, treated or referred, disclosed and documented"
        },
        {
          "detail": "Ask about or check temperature, degree of jaw opening restriction (trismus), how far swelling extends, and pain severity; ask whether the patient can come into the office same-day.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Assess severity: fever, trismus, extent of swelling, pain level"
        },
        {
          "detail": "Significant trismus, fever above a low-grade level, or swelling extending beyond the immediate surgical site favors urgent referral over office-only management.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "office",
              "label": "Same-day office visit and antibiotics"
            },
            {
              "goto": "s11",
              "id": "urgent-referral",
              "label": "Urgent specialist or ED referral"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this manageable with same-day in-office evaluation and antibiotics, or does it need urgent specialist/ED referral?"
        },
        {
          "detail": "Bring the patient in same-day for exam, consider incision and drainage if a fluctuant abscess is present, and prescribe antibiotics per current openly published guidance if indicated.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "See the patient same-day, examine and prescribe if indicated"
        },
        {
          "detail": "The dentist explains the assessment and plan, and explicitly tells the patient to go to the nearest emergency department or call 911 immediately if breathing or swallowing becomes difficult at any point, even after leaving.\n\nWhy: Post-surgical infections can worsen after the visit; the patient must leave knowing exactly which symptoms mean 'go to the ER now,' not 'call in the morning.'",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the finding and the plan, and confirm the patient knows the warning signs.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Disclose the finding and the plan, and confirm the patient knows the warning signs",
          "why": "Post-surgical infections can worsen after the visit; the patient must leave knowing exactly which symptoms mean 'go to the ER now,' not 'call in the morning.'"
        },
        {
          "detail": "Front desk or dentist calls the patient within 24 hours to confirm symptoms are improving, not worsening, and that any referral appointment was kept.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Place a follow-up call within 24 hours"
        },
        {
          "detail": "Contact the specialist referral office or nearest emergency department directly, describe the clinical picture, and confirm the patient is being seen the same day.",
          "id": "s11",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Arrange urgent specialist or emergency department evaluation"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Post-surgical infection with spreading swelling — antibiotics versus emergency referral — Swelling, trismus, fever or difficulty swallowing after a surgical procedure — airway compromise goes to 911 first.",
      "title": "Post-surgical infection with spreading swelling — antibiotics versus emergency referral",
      "trigger": "Swelling, trismus, fever or difficulty swallowing after a surgical procedure — airway compromise goes to 911 first",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published third-molar guidance (nerve proximity and paresthesia risk)",
          "source": "ADA/AAOMS openly published third-molar guidance (nerve proximity and paresthesia risk)",
          "url": "https://aaoms.org/wp-content/uploads/2024/07/impacted_third_molars.pdf"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent: structured neurosensory testing and recall interval for paresthesia — not tied to any institute protocol",
          "source": "Generic functional equivalent: structured neurosensory testing and recall interval for paresthesia — not tied to any institute protocol"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "osx-015",
      "kind": "clinical",
      "materials": [
        "neurosensory testing tools (light touch, sharp/dull, two-point discrimination)",
        "chart/practice management system",
        "phone for specialist referral"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral",
        "front-desk",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask when the numbness started, its location (lip, chin, tongue, cheek), and which recent procedure or injection preceded it. Confirm it extends well beyond the expected local-anesthetic duration for the anesthetic used.\n\nWhy: Distinguishing lingering normal anesthesia from true paresthesia sets the right urgency for the rest of the workup.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the numbness report and its relation to a recent procedure",
          "why": "Distinguishing lingering normal anesthesia from true paresthesia sets the right urgency for the rest of the workup."
        },
        {
          "detail": "Bring the patient in as soon as practical, ideally within a few days, for a structured neurosensory exam rather than waiting to see if it resolves unassessed.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a prompt neurosensory examination"
        },
        {
          "detail": "Test and record light touch, sharp/dull discrimination, and two-point discrimination across the affected area; map the extent of the numb region; note the patient's subjective description (numb, tingling, painful).\n\nWhy: A baseline structured exam is what allows later exams to show improvement, no change, or worsening — without it, recovery cannot be tracked objectively.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Perform and document a structured neurosensory exam",
          "why": "A baseline structured exam is what allows later exams to show improvement, no change, or worsening — without it, recovery cannot be tracked objectively."
        },
        {
          "detail": "The dentist explains the nerve injury finding, that most such injuries improve over weeks to months but some do not fully resolve, and the plan for monitoring or referral.\n\nWhy: Direct, honest disclosure of a nerve injury is expected practice, including realistic expectations about the range of possible outcomes.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the finding and the plan to the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Disclose the finding and the plan to the patient",
          "why": "Direct, honest disclosure of a nerve injury is expected practice, including realistic expectations about the range of possible outcomes."
        },
        {
          "detail": "Consider the extent and severity of numbness, whether it is a light-touch or sharp/dull deficit, and how far past the immediate post-operative period the report arrived.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "monitor",
              "label": "Monitor with a recall exam schedule"
            },
            {
              "goto": "s10",
              "id": "refer",
              "label": "Refer to a specialist now for evaluation"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Monitor with a recall schedule, or refer to a specialist now?"
        },
        {
          "detail": "Book follow-up neurosensory exams at the office's standard intervals (e.g. monthly) to track improvement, no change, or worsening.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Set a recall exam schedule"
        },
        {
          "detail": "At each recall: is the deficit improving, unchanged, or worsening past the referral threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "improving",
              "label": "Improving — continue monitoring"
            },
            {
              "goto": "s10",
              "id": "no-improvement",
              "label": "Unchanged or worsening past the referral threshold"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "At each recall: is the deficit improving, unchanged, or worsening past the referral threshold?"
        },
        {
          "detail": "Record the case and exam findings in the practice's complication log for the monthly quality review, generic front-office record-keeping.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the case for the monthly complication review"
        },
        {
          "detail": "Paresthesia assessed, disclosed, monitored or referred, and documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Paresthesia assessed, disclosed, monitored or referred, and documented"
        },
        {
          "detail": "Send the neurosensory exam findings over time and the operative note to the specialist referral office and confirm an appointment.",
          "id": "s10",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Hand off to a specialist referral with the neurosensory exam history"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Nerve injury or paresthesia after surgery or injection — documentation and follow-up — A patient reports persistent numbness beyond the expected anesthesia window.",
      "title": "Nerve injury or paresthesia after surgery or injection — documentation and follow-up",
      "trigger": "A patient reports persistent numbness beyond the expected anesthesia window",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOMS White Paper on Third Molar Data + JADA 'The indications for third-molar extractions' — third-molar complication management only",
          "repaired": {
            "action": "reduce",
            "evidence": "'Third-molar teeth that are associated with disease, or are at high risk of developing disease, should be surgically managed'; pericoronitis is described as 'a typical inflammatory pathology of the impacted or partially impacted third molar... accepted treatment regimens including antibiotic therapy coupled with surgical intervention'; oroantral communication is described as 'an unnatural communication of the maxillary sinus with the oral cavity, often resulting from dental extractions... In case of an infected oroantral communication or fistula, priority rests on treating the infection first and followed by surgical repair.' (search results, AAOMS/JADA/PMC sources on third-molar guidelines.)",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAOMS openly published third-molar and antibiotic guidance",
              "url": null
            }
          },
          "source": "AAOMS White Paper on Third Molar Data (aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf); JADA, 'The indications for third-molar extractions' (jada.ada.org/article/S0002-8177(14)60117-3/fulltext). Scope: osx-009 (fractured root tip), osx-010 (oroantral communication), osx-011 (tooth/fragment displaced into sinus), osx-014 (post-surgical infection/antibiotics), osx-016 (pericoronitis) only — does NOT reach osx-012 (soft-tissue biopsy submission chain), which is an oral-pathology specimen-handling matter, not a third-molar guideline topic.",
          "url": "https://aaoms.org/wp-content/uploads/2024/03/white_paper_third_molar_data.pdf"
        },
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent: irrigation and debridement first-line, antibiotics for spreading signs, extraction timing after resolution — not tied to any institute protocol",
          "source": "Generic functional equivalent: irrigation and debridement first-line, antibiotics for spreading signs, extraction timing after resolution — not tied to any institute protocol"
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "osx-016",
      "kind": "clinical",
      "materials": [
        "irrigation syringe with antiseptic solution",
        "periapical/panoramic radiograph",
        "prescription pad",
        "post-op instruction handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Examine the operculum over the partially erupted tooth for swelling, pus, and trauma from the opposing tooth; check for trismus, facial swelling, fever, or difficulty swallowing that would indicate spread beyond the local tissue.\n\nWhy: Distinguishing a local, self-contained pericoronitis from one with systemic or spreading signs determines whether this stays a routine visit or escalates toward osx-014.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Assess local versus spreading signs",
          "why": "Distinguishing a local, self-contained pericoronitis from one with systemic or spreading signs determines whether this stays a routine visit or escalates toward osx-014."
        },
        {
          "detail": "Are there spreading or systemic signs (fever, trismus, facial swelling, difficulty swallowing)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "local",
              "label": "Local signs only"
            },
            {
              "goto": "s12",
              "id": "spreading",
              "label": "Spreading or systemic signs present"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Are there spreading or systemic signs (fever, trismus, facial swelling, difficulty swallowing)?"
        },
        {
          "detail": "Gently irrigate beneath the soft tissue flap with an antiseptic solution to flush out debris and plaque; remove any obvious food impaction.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Irrigate and debride under the operculum"
        },
        {
          "detail": "Is the opposing tooth traumatizing the operculum on closure?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-trauma",
              "label": "No occlusal trauma"
            },
            {
              "goto": "s13",
              "id": "trauma",
              "label": "Opposing tooth traumatizing the site"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the opposing tooth traumatizing the operculum on closure?"
        },
        {
          "detail": "Local measures alone are the first-line approach per current openly published guidance; reserve antibiotics for cases with regional lymphadenopathy or low-grade systemic involvement short of the spreading-infection threshold.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "local-only",
              "label": "Local measures only, no antibiotic"
            },
            {
              "goto": "s15",
              "id": "antibiotic",
              "label": "Prescribe an antibiotic"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does this case warrant a systemic antibiotic?"
        },
        {
          "detail": "Instruct on warm saltwater rinses, gentle brushing of the area, soft diet, and analgesic use per current opioid-sparing prescribing guidance if pain medication is needed.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Give home-care instructions and pain management guidance"
        },
        {
          "detail": "The dentist confirms and documents the treatment plan given to the patient — local measures, any antibiotic prescribed, and the extraction-timing plan — before the patient is dismissed.\n\nWhy: A pericoronitis treatment plan carries a prescribing decision and a downstream extraction decision; a licensed sign-off before dismissal keeps that judgment with the dentist rather than defaulting silently.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the treatment plan before dismissal.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the treatment plan before dismissal",
          "why": "A pericoronitis treatment plan carries a prescribing decision and a downstream extraction decision; a licensed sign-off before dismissal keeps that judgment with the dentist rather than defaulting silently."
        },
        {
          "detail": "Once the acute episode resolves, decide whether extraction of the involved third molar is indicated and when — extracting during acute infection is generally avoided per open standard guidance.",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "schedule-extraction",
              "label": "Schedule extraction after acute resolution"
            },
            {
              "goto": "s9",
              "id": "no-extraction",
              "label": "No extraction planned — monitor for recurrence"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Plan for third-molar extraction now that acute symptoms are resolving?"
        },
        {
          "detail": "Book a follow-up visit within about a week to confirm the episode has resolved and to proceed with any planned extraction.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up to confirm resolution"
        },
        {
          "detail": "Record the case, treatment given, and extraction plan in the practice's clinical log for the monthly quality review, generic front-office record-keeping.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the case for the monthly clinical review"
        },
        {
          "detail": "Pericoronitis assessed, treated or escalated, and follow-up planned",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Pericoronitis assessed, treated or escalated, and follow-up planned"
        },
        {
          "detail": "Switch to the practice's post-surgical infection protocol (osx-014), which starts with the airway safety gate.\n\nWhy: Spreading signs from pericoronitis are managed the same way as any spreading odontogenic infection — airway assessment first.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Escalate to the post-surgical/spreading infection protocol",
          "why": "Spreading signs from pericoronitis are managed the same way as any spreading odontogenic infection — airway assessment first."
        },
        {
          "detail": "Consider adjusting or extracting the opposing tooth if it is directly traumatizing the inflamed operculum on every closure, per clinical judgment; this visit's consent covers the third molar only, so treat this as a separate procedure requiring its own consent before acting.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Address the traumatizing opposing tooth"
        },
        {
          "detail": "This visit's consent covers pericoronitis management of the third molar only. If adjustment or extraction of the opposing tooth is indicated, explain that risk/benefit separately and obtain the patient's explicit consent — or defer it to another visit — before proceeding.\n\nWhy: Treating a different tooth is outside the scope of the pericoronitis consent already on file and needs its own explicit patient agreement.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain separate consent before adjusting or extracting the opposing tooth.",
            "type": "safety"
          },
          "id": "s14",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain separate consent before adjusting or extracting the opposing tooth",
          "why": "Treating a different tooth is outside the scope of the pericoronitis consent already on file and needs its own explicit patient agreement."
        },
        {
          "detail": "Select and prescribe an antibiotic per current openly published prescribing guidance, considering allergies documented in the chart.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe an antibiotic per current guidance"
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Pericoronitis management — A patient presents with pain and swelling over a partially erupted third molar.",
      "title": "Pericoronitis management",
      "trigger": "A patient presents with pain and swelling over a partially erupted third molar",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "ADA/AAOMS openly published pathology follow-up and results-tracking guidance",
          "source": "ADA/AAOMS openly published pathology follow-up and results-tracking guidance"
        },
        {
          "kind": "generic",
          "label": "10-business-day overdue threshold and three-contact-attempt escalation — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "10-business-day overdue threshold and three-contact-attempt escalation: generic functional equivalent"
          },
          "source": "10-business-day overdue threshold and three-contact-attempt escalation — Practice policy — no published authority governs this step."
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "osx-017",
      "kind": "clinical",
      "materials": [
        "biopsy tracking log / tickler system",
        "laboratory phone number and specimen accession number",
        "patient contact information on file",
        "certified mail supplies or equivalent trackable delivery",
        "chart / record system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "office-manager",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Front desk reviews the biopsy tracking log daily; flags any specimen submitted more than 10 business days ago with no report on file, or any patient with a result on hand for whom three contact attempts have already failed.\n\nWhy: A biopsy result is time-sensitive information the practice is obligated to deliver; a log is the only reliable way to catch a result that silently never arrived.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the case as overdue or the patient as unreachable",
          "why": "A biopsy result is time-sensitive information the practice is obligated to deliver; a log is the only reliable way to catch a result that silently never arrived."
        },
        {
          "detail": "Confirm from the log whether this is a missing report from the laboratory, or a report in hand with an unreachable patient.\n\nWhy: The two situations have different next actions — one chases the lab, the other chases the patient.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "report-missing",
              "label": "Report never arrived from the lab"
            },
            {
              "goto": "s11",
              "id": "patient-unreachable",
              "label": "Report in hand, patient unreachable"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Determine which situation applies",
          "why": "The two situations have different next actions — one chases the lab, the other chases the patient."
        },
        {
          "detail": "Front desk or office manager calls the laboratory, references the specimen accession number and submission date, and asks for status: in process, result pending physician sign-off, or never received.\n\nWhy: Most overdue results are a processing delay the lab can resolve on the spot with a status update or an estimated completion date.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Call the laboratory with the accession number",
          "why": "Most overdue results are a processing delay the lab can resolve on the spot with a status update or an estimated completion date."
        },
        {
          "detail": "Lab reports either a completion date, or that the specimen was never received / cannot be located.\n\nWhy: If the specimen itself is missing, this stops being a delay and becomes a specimen-loss incident with its own protocol.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "eta-given",
              "label": "Lab gives a completion date"
            },
            {
              "goto": "s15",
              "id": "specimen-not-found",
              "label": "Lab cannot locate the specimen"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Lab confirms status",
          "why": "If the specimen itself is missing, this stops being a delay and becomes a specimen-loss incident with its own protocol."
        },
        {
          "detail": "Update the tracking log entry with lab-confirmed status, new expected completion date, and who made the call.\n\nWhy: Without a written re-check date the case can silently go overdue again.\n\nRecord: Tracking log entry updated with lab-confirmed status, new expected completion date, and who made the call.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the new expected date and set a follow-up reminder",
          "why": "Without a written re-check date the case can silently go overdue again."
        },
        {
          "detail": "Hold the case open until the new expected date arrives; front desk re-checks the tracking log on that date.\n\nWhy: Gives the lab its own stated turnaround before escalating further.\n\nCadence: an unspecified interval (no valid timer duration in source — downgraded from a timer step).",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Wait until the lab-confirmed date, then re-check",
          "why": "Gives the lab its own stated turnaround before escalating further."
        },
        {
          "detail": "Front desk checks whether the report has now been received.\n\nWhy: A second miss on a lab-committed date warrants a higher-level escalation than the first.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "arrived",
              "label": "Result arrived"
            },
            {
              "goto": "s16",
              "id": "still-missing",
              "label": "Still missing"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the result arrive by the new date?",
          "why": "A second miss on a lab-committed date warrants a higher-level escalation than the first."
        },
        {
          "detail": "Once the result is in hand and the patient reachable, or the dentist has directed a specific delivery path, hand the case to the standard result-receipt and notification protocol for delivery of the finding.\n\nWhy: Keeps result delivery in one consistent, HITL-gated workflow regardless of how the case became overdue.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the pathology-report receipt and patient-notification protocol",
          "why": "Keeps result delivery in one consistent, HITL-gated workflow regardless of how the case became overdue."
        },
        {
          "detail": "Mark the tracking log entry resolved with date, final outcome, and dentist sign-off reference.\n\nWhy: An open tracking log with no closure is the same failure mode that let the case go overdue in the first place.\n\nRecord: Tracking log entry marked resolved with date, final outcome (result delivered / routed to specimen-loss protocol), and dentist sign-off reference.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Close out the tracking log entry",
          "why": "An open tracking log with no closure is the same failure mode that let the case go overdue in the first place."
        },
        {
          "detail": "Case closed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Case closed"
        },
        {
          "detail": "Confirm the log shows three attempts across different times/days and at least two different contact methods (phone, then a second phone attempt or an alternate number, then a written notice), each dated and initialed.\n\nWhy: Documenting a genuine good-faith effort protects both the patient's right to know and the practice against a later claim that no attempt was made.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Review the three prior contact attempts on file",
          "why": "Documenting a genuine good-faith effort protects both the patient's right to know and the practice against a later claim that no attempt was made."
        },
        {
          "detail": "Confirm the log meets the three-attempt, mixed-method standard before escalating to certified mail.\n\nWhy: Escalating to certified mail before genuinely exhausting phone contact wastes the more resource-intensive step.",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "sufficient",
              "label": "Yes, three attempts across methods on file"
            },
            {
              "goto": "s17",
              "id": "insufficient",
              "label": "No, attempts incomplete"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "office-manager",
          "title": "Were three documented attempts, across methods, actually made?",
          "why": "Escalating to certified mail before genuinely exhausting phone contact wastes the more resource-intensive step."
        },
        {
          "detail": "Office manager sends a letter to the patient's address on file by certified mail or another delivery method with proof of delivery, stating only that a result is ready for discussion and asking the patient to call the office. The letter does not state the result itself.\n\nWhy: A trackable, documented attempt to reach the patient is the standard of care when phone contact has failed; the result itself is not disclosed by letter because it should be delivered by the dentist directly.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Send a certified letter (or equivalent trackable notice) asking the patient to contact the office",
          "why": "A trackable, documented attempt to reach the patient is the standard of care when phone contact has failed; the result itself is not disclosed by letter because it should be delivered by the dentist directly."
        },
        {
          "detail": "The treating dentist reviews every case that reaches this point — lab-side delays exceeding the second date, or a patient still unreachable after certified mail — and personally decides the next step: continued attempts, a different specialist referral for delivery of the result, or another approach.\n\nWhy: A significant delay in delivering a biopsy result is a clinical and risk-management decision that must not be closed out by administrative staff alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the overdue case before it is closed or further escalated.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s14",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the overdue case before it is closed or further escalated",
          "why": "A significant delay in delivering a biopsy result is a clinical and risk-management decision that must not be closed out by administrative staff alone."
        },
        {
          "detail": "When the laboratory cannot locate the specimen at all, hand the case to the specimen-loss protocol rather than continuing to treat it as a simple delay.\n\nWhy: A missing specimen requires patient disclosure and a re-biopsy discussion, which is a materially different process than waiting on a slow report.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the specimen lost/mislabeled/rejected protocol",
          "why": "A missing specimen requires patient disclosure and a re-biopsy discussion, which is a materially different process than waiting on a slow report."
        },
        {
          "detail": "Office manager contacts the laboratory's account or pathology department manager directly, referencing the prior calls and the missed date, and requests a specific resolution timeline in writing (email or fax confirmation).\n\nWhy: A pattern of missed dates needs a manager-to-manager conversation rather than another front-desk call to the same queue.",
          "id": "s16",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the office manager for direct lab-management contact",
          "why": "A pattern of missed dates needs a manager-to-manager conversation rather than another front-desk call to the same queue."
        },
        {
          "detail": "Front desk completes the missing attempt(s) using an alternate phone number, emergency contact on file, or a different time of day, and logs each with date, method and outcome.\n\nWhy: Closes the documentation gap before the escalation step is taken.",
          "id": "s17",
          "kind": "step",
          "role": "front-desk",
          "title": "Make the remaining contact attempt(s) before escalating",
          "why": "Closes the documentation gap before the escalation step is taken."
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Pending pathology result overdue, or patient unreachable for a biopsy result — No report has arrived 10 business days after submission, or three attempts to reach the patient with a result have failed.",
      "title": "Pending pathology result overdue, or patient unreachable for a biopsy result",
      "trigger": "No report has arrived 10 business days after submission, or three attempts to reach the patient with a result have failed",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute)"
          },
          "source": "Office disclosure policy: prompt, direct patient disclosure of an unexpected surgical finding or adverse event, grounded in general informed-consent and standard-of-care duties rather than a specific disclosure-timing statute (CA B&P §1680 lists grounds for Dental Board discipline; it is not itself an affirmative same-visit-disclosure statute) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "— specimen chain-of-custody handling, no single named authority confirmed — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "generic functional equivalent — specimen chain-of-custody handling, no single named authority confirmed"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Ran two independent web searches (\"ADA AAOMS biopsy specimen chain of custody labeling guidance oral pathology\" and \"'AAOMS' biopsy specimen handling submission pathology laboratory guideline\"). Both returned only unrelated general pathology-society material (CAP thoracic-biopsy protocol, AST surgical-specimen standard, veterinary/patent documents) with no ADA-authored or AAOMS-authored chain-of-custody document appearing in either result set.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/AAOMS openly published pathology chain-of-custody and specimen-handling guidance",
              "url": null
            }
          },
          "source": "— specimen chain-of-custody handling, no single named authority confirmed — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Specimen submission log and incident report format — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Specimen submission log and incident report format: generic functional equivalent"
          },
          "source": "Specimen submission log and incident report format — Practice policy — no published authority governs this step."
        }
      ],
      "class": "oral-surgery-extractions",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "osx-018",
      "kind": "clinical",
      "materials": [
        "specimen submission log (specimen ID, container, fixative, courier/mail tracking)",
        "laboratory requisition form copy",
        "chart / record system",
        "incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "office-manager",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Office manager or front desk receives the laboratory's report of a problem (no specimen received, labeling does not match the requisition, or inadequate fixation renders the tissue unreadable) and confirms it in writing (email or fax) if the initial notice was verbal.\n\nWhy: A written confirmation prevents a miscommunication about which specimen and which problem is at issue.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and confirm the laboratory's notice",
          "why": "A written confirmation prevents a miscommunication about which specimen and which problem is at issue."
        },
        {
          "detail": "Office manager retrieves the log entry made at the time of submission: specimen ID, container labeling, fixative used, date sent, and courier or mail tracking number.\n\nWhy: The submission log is the only record that can establish what actually left the office and how, independent of the lab's account.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the specimen submission log for this case",
          "why": "The submission log is the only record that can establish what actually left the office and how, independent of the lab's account."
        },
        {
          "detail": "Determine from the lab's notice and the submission log which of the three failure types applies.\n\nWhy: Each failure type has a different root-cause trail and a different re-biopsy urgency.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "lost",
              "label": "No specimen received (lost in transit or never sent)"
            },
            {
              "goto": "s13",
              "id": "mislabeled",
              "label": "Labeling mismatch with requisition"
            },
            {
              "goto": "s5",
              "id": "rejected",
              "label": "Inadequate fixation, specimen rejected"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Classify the problem",
          "why": "Each failure type has a different root-cause trail and a different re-biopsy urgency."
        },
        {
          "detail": "Office manager checks the tracking number logged at submission with the courier or postal service to determine whether the package was delivered, lost in transit, or never actually shipped.\n\nWhy: Establishes whether this is a shipping failure (specimen may be recoverable) or an in-office failure (specimen was never packaged for shipment).",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Trace the courier or mail tracking number",
          "why": "Establishes whether this is a shipping failure (specimen may be recoverable) or an in-office failure (specimen was never packaged for shipment)."
        },
        {
          "detail": "The assistant who prepared and submitted the specimen documents, from memory and the log, exactly how the specimen was collected, placed in fixative, labeled, and packaged.\n\nWhy: A first-hand account close to the event is more reliable than reconstructing it later, and it feeds the root-cause finding.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Assistant reviews the original submission procedure for this case",
          "why": "A first-hand account close to the event is more reliable than reconstructing it later, and it feeds the root-cause finding."
        },
        {
          "detail": "Based on the trace/label comparison/fixation review, the dentist determines whether the lab can still process the existing specimen (e.g., a labeling fix with unambiguous chain of custody) or whether the tissue is unusable and a new specimen is needed.\n\nWhy: This decision determines whether the patient needs a second procedure, which is the central fact they must be told.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "recoverable",
              "label": "Specimen recoverable, lab can proceed"
            },
            {
              "goto": "s7",
              "id": "not-recoverable",
              "label": "Not recoverable, re-biopsy required"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the specimen recoverable, or is re-biopsy required?",
          "why": "This decision determines whether the patient needs a second procedure, which is the central fact they must be told."
        },
        {
          "detail": "The treating dentist reviews the root-cause finding and the recoverable/not-recoverable determination, and personally approves what will be disclosed to the patient before any contact is made.\n\nWhy: Disclosure of a specimen-handling error is a clinical and risk-management communication that must not be delegated to administrative staff without the dentist's review.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before the patient is contacted.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before the patient is contacted",
          "why": "Disclosure of a specimen-handling error is a clinical and risk-management communication that must not be delegated to administrative staff without the dentist's review."
        },
        {
          "detail": "Dentist (or the dentist directly overseeing the call) contacts the patient, explains in plain language what happened, whether the existing specimen can still be processed, and if not, that a repeat biopsy is needed and why.\n\nWhy: The patient has a right to know about a handling error affecting their own tissue sample and the reason for any repeat procedure.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Disclose the incident to the patient",
          "why": "The patient has a right to know about a handling error affecting their own tissue sample and the reason for any repeat procedure."
        },
        {
          "detail": "Confirm the outcome of the root-cause decision to determine whether scheduling is required.\n\nWhy: Routes the case correctly depending on whether new tissue must be obtained.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "yes-repeat",
              "label": "Yes, schedule repeat biopsy"
            },
            {
              "goto": "s11",
              "id": "no-repeat",
              "label": "No, lab proceeding with existing specimen"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a repeat biopsy needed?",
          "why": "Routes the case correctly depending on whether new tissue must be obtained."
        },
        {
          "detail": "Office manager schedules the repeat biopsy visit and hands the case to the soft-tissue biopsy and pathology submission protocol, flagged as a repeat with a note on the prior incident.\n\nWhy: Keeps the repeat procedure inside the standard biopsy workflow rather than as an ad hoc booking.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the standard biopsy protocol to schedule and perform the repeat procedure",
          "why": "Keeps the repeat procedure inside the standard biopsy workflow rather than as an ad hoc booking."
        },
        {
          "detail": "Complete an incident report with specimen ID, failure type, root cause, and one concrete process fix.\n\nWhy: Recording the specific root cause and a concrete fix is what prevents the same failure from recurring, not just documenting that it happened.\n\nRecord: Incident report completed: specimen ID, failure type, root cause, patient disclosure date and method, repeat-procedure status, and one specific process change (e.g., a second-person label check before submission) reviewed by the office manager and dentist.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "File an internal incident report and identify a process fix",
          "why": "Recording the specific root cause and a concrete fix is what prevents the same failure from recurring, not just documenting that it happened."
        },
        {
          "detail": "Incident closed",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Incident closed"
        },
        {
          "detail": "Assistant and office manager compare the specimen container label, the requisition form sent with it, and the chart entry side by side to identify exactly where the mismatch occurred.\n\nWhy: Pinpointing whether the error is on the container, the form, or a transcription step drives the correction and the process fix.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Compare the container label against the requisition form and chart",
          "why": "Pinpointing whether the error is on the container, the form, or a transcription step drives the correction and the process fix."
        }
      ],
      "subclass": "oral-surgery-extractions-and-biopsy",
      "summary": "Biopsy specimen lost, mislabeled or rejected by the laboratory — The lab reports no specimen received, a labeling mismatch, or inadequate fixation.",
      "title": "Biopsy specimen lost, mislabeled or rejected by the laboratory",
      "trigger": "The lab reports no specimen received, a labeling mismatch, or inadequate fixation",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "source": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "url": "https://ubwp.buffalo.edu/rdc-tmdinternational/"
        },
        {
          "kind": "generic",
          "label": "Occlusal contact examination technique (centric contacts, working/non-working excursions, wear facet documentation): generic functional equivalent",
          "source": "Occlusal contact examination technique (centric contacts, working/non-working excursions, wear facet documentation): generic functional equivalent"
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "otmd-001",
      "kind": "clinical",
      "materials": [
        "articulating paper (two colors)",
        "mouth mirror",
        "intraoral camera",
        "cotton rolls/air syringe"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Assistant seats the patient and reviews any reported grinding, chipping, jaw fatigue, or headache symptoms already noted in the chart before the exam begins.\n\nWhy: Knowing the reported symptom up front focuses where the dentist looks first.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Seat patient and review chief complaint",
          "why": "Knowing the reported symptom up front focuses where the dentist looks first."
        },
        {
          "detail": "Assistant dries both arches with air and retracts the cheeks; dentist positions the mirror for a clear view of occlusal and incisal surfaces.\n\nWhy: A dry field reveals wear facets and cracks that saliva sheen can obscure.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Dry and visualize the arches",
          "why": "A dry field reveals wear facets and cracks that saliva sheen can obscure."
        },
        {
          "detail": "Dentist has the patient close in centric occlusion/relation and marks contacts with articulating paper, noting whether contacts are bilateral and simultaneous.\n\nWhy: Uneven or unilateral centric contacts are a common driver of parafunction and tooth wear.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "articulating paper"
          ],
          "role": "dentist",
          "title": "Mark and record centric contacts",
          "why": "Uneven or unilateral centric contacts are a common driver of parafunction and tooth wear."
        },
        {
          "detail": "Dentist guides the patient through right lateral, left lateral, and protrusive movements, marking and noting working-side and non-working-side (balancing) contacts and whether canine or group-function guidance is present.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Mark and record excursive contacts"
        },
        {
          "detail": "Checklist by quadrant: flattened cusp tips, incisal chipping, cervical abfraction notches, tooth mobility grade, fremitus on function, and presence of tori.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Assess and document wear pattern findings"
        },
        {
          "detail": "Assistant captures intraoral photos of significant wear facets and articulating-paper marks for the chart before the marks are wiped away.\n\nWhy: A photographic record lets a future exam compare wear progression objectively.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "intraoral camera"
          ],
          "role": "assistant",
          "title": "Photograph wear facets and contact marks",
          "why": "A photographic record lets a future exam compare wear progression objectively."
        },
        {
          "detail": "Dentist reviews the contact map, wear pattern, mobility and photographs together and determines whether findings indicate active parafunction warranting further TMD workup, before anything is presented to the patient as a diagnosis.\n\nWhy: Occlusal findings alone are descriptive; only a licensed provider can interpret them into a clinical determination.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed review before findings become a diagnosis.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed review before findings become a diagnosis",
          "why": "Occlusal findings alone are descriptive; only a licensed provider can interpret them into a clinical determination."
        },
        {
          "detail": "Record the centric and excursive contact map, wear facet locations, mobility grades, and the dentist's interpretation in the chart.\n\nRecord: occlusal contact map, wear facet locations, mobility grades, dentist interpretation",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the exam in the chart"
        },
        {
          "detail": "Dentist decides, based on the documented findings, whether the exam concludes here or a TMD screening is warranted.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "no-further-workup",
              "label": "No significant wear, mobility or contact issue found"
            },
            {
              "goto": "s11",
              "id": "further-workup",
              "label": "Significant wear, mobility or symptoms present"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether further TMD workup is needed"
        },
        {
          "detail": "Occlusal examination complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Occlusal examination complete"
        },
        {
          "detail": "Dentist hands the finding off into the TMD screening questionnaire and exam protocol (otmd-002) for further workup at this visit or the next.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to TMD screening"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Occlusal examination — centric contacts, excursions, wear patterns, mobility — A comprehensive exam, or a patient reports grinding, chipping or jaw fatigue.",
      "title": "Occlusal examination — centric contacts, excursions, wear patterns, mobility",
      "trigger": "A comprehensive exam, or a patient reports grinding, chipping or jaw fatigue",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "source": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "url": "https://ubwp.buffalo.edu/rdc-tmdinternational/"
        },
        {
          "kind": "open_standard",
          "label": "AAOP orofacial pain guidelines (openly published)",
          "source": "AAOP orofacial pain guidelines (openly published)",
          "url": "https://aaop.org/"
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "otmd-002",
      "kind": "clinical",
      "materials": [
        "TMD screening questionnaire form",
        "millimeter ruler",
        "gloves"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Hygienist gives the patient the standardized TMD screening questionnaire covering jaw pain, clicking, locking and headache history before the clinical exam begins.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "TMD screening questionnaire form"
          ],
          "role": "hygienist",
          "title": "Administer the TMD screening questionnaire"
        },
        {
          "detail": "Dentist reviews the patient's completed questionnaire responses and flags any positive items for follow-up during the exam.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Review the completed questionnaire"
        },
        {
          "detail": "Dentist measures maximum unassisted mouth opening, lateral excursion and protrusive movement in millimeters with a ruler, and notes any deviation or deflection during opening.\n\nWhy: Reduced or asymmetric range of motion is a core diagnostic criterion under the public DC/TMD framework.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "millimeter ruler"
          ],
          "role": "dentist",
          "title": "Measure range of motion",
          "why": "Reduced or asymmetric range of motion is a core diagnostic criterion under the public DC/TMD framework."
        },
        {
          "detail": "Palpate masseter and temporalis bilaterally (and lateral/medial pterygoid regions if trained) and note tenderness on a 0-3 scale for each site.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Palpate the masticatory muscles"
        },
        {
          "detail": "Palpate the TMJ bilaterally at rest and during opening/closing for tenderness, clicking, crepitus, or locking, and note findings for each side.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Palpate the TMJ"
        },
        {
          "detail": "Dentist weighs the combined questionnaire, range-of-motion and palpation findings for anything inconsistent with a routine TMD picture (unexplained numbness, swelling, fever, systemic signs).",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-red-flags",
              "label": "Pattern is consistent with muscular/joint TMD"
            },
            {
              "goto": "s12",
              "id": "red-flags-present",
              "label": "Findings suggest a non-TMD source"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Check for red flags outside a muscular/joint origin"
        },
        {
          "detail": "Dentist reviews the questionnaire, ROM measurements and palpation findings together to confirm a TMD diagnosis before it is entered as a diagnosis and a management plan is offered to the patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed review before a TMD diagnosis is entered.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed review before a TMD diagnosis is entered"
        },
        {
          "detail": "Record the questionnaire score, ROM measurements in millimeters, palpation tenderness scores, and the diagnostic impression in the chart.\n\nRecord: questionnaire score, ROM in mm, palpation scores, diagnostic impression",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the diagnosis"
        },
        {
          "detail": "Dentist decides whether to proceed to a conservative management plan now or hold for a re-screen at the next recall.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "conservative",
              "label": "Diagnosis has no red flags — proceed to conservative management"
            },
            {
              "goto": "s11",
              "id": "monitor",
              "label": "Mild or inconclusive findings — re-screen at next recall"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide the management path"
        },
        {
          "detail": "Dentist hands the diagnosed case off to the TMD conservative management protocol (otmd-003) to begin the home-care program.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to conservative management"
        },
        {
          "detail": "TMD screening complete",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "TMD screening complete"
        },
        {
          "detail": "Dentist hands the case off to the orofacial pain red-flag referral protocol (otmd-004) instead of proceeding with a TMD diagnosis.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to red-flag referral"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "TMD screening questionnaire, range of motion and palpation exam — A patient reports jaw pain, clicking, locking or headaches.",
      "title": "TMD screening questionnaire, range of motion and palpation exam",
      "trigger": "A patient reports jaw pain, clicking, locking or headaches",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOP orofacial pain guidelines (openly published)",
          "source": "AAOP orofacial pain guidelines (openly published)",
          "url": "https://aaop.org/"
        },
        {
          "kind": "open_standard",
          "label": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "source": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "url": "https://ubwp.buffalo.edu/rdc-tmdinternational/"
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "otmd-003",
      "kind": "clinical",
      "materials": [
        "home-care instruction sheet",
        "cold pack",
        "jaw stretching exercise handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist confirms the TMD diagnosis from the screening exam (otmd-002) carries no red flags requiring referral before starting a home-care program.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the diagnosis has no red flags"
        },
        {
          "detail": "Dentist explains the TMD diagnosis in plain language, including that most muscular TMD improves with conservative self-care over several weeks.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the diagnosis and expected course"
        },
        {
          "detail": "Dentist reviews and signs off on the specific home-care plan — soft-diet duration, thermal therapy, and any over-the-counter analgesic guidance — before it is given to the patient.\n\nWhy: Recommending an analgesic regimen, even over-the-counter, is a clinical instruction that must be attributed to the licensed provider.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the home-care plan.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the home-care plan",
          "why": "Recommending an analgesic regimen, even over-the-counter, is a clinical instruction that must be attributed to the licensed provider."
        },
        {
          "detail": "Instruct a soft-diet and avoidance of wide yawning, gum chewing, and hard or chewy foods for the recommended period.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Instruct the soft-diet period"
        },
        {
          "detail": "Instruct alternating moist heat and cold pack application to the jaw muscles as directed on the home-care instruction sheet.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "home-care instruction sheet",
            "cold pack"
          ],
          "role": "dentist",
          "title": "Instruct thermal therapy"
        },
        {
          "detail": "Instruct voluntary jaw rest — lips together, teeth apart, tongue relaxed — and gentle self-massage of the masseter and temporalis.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Instruct jaw rest posture"
        },
        {
          "detail": "Document the over-the-counter analgesic guidance given per label dosing, and the symptom threshold (e.g., worsening or unchanged pain after two weeks) that should prompt a return visit rather than continued self-management.\n\nWhy: A documented threshold gives the patient a clear signal to return instead of self-managing indefinitely.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the analgesic guidance and escalation threshold",
          "why": "A documented threshold gives the patient a clear signal to return instead of self-managing indefinitely."
        },
        {
          "detail": "Give the patient a checklist of gentle jaw stretching and range-of-motion home exercises to perform daily.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "jaw stretching exercise handout"
          ],
          "role": "dentist",
          "title": "Give the home exercise checklist"
        },
        {
          "detail": "Front desk schedules a follow-up visit in 2 to 4 weeks to reassess symptoms and appliance candidacy.\n\nWhy: Booking the follow-up uses the same generic scheduling flow as any recall visit.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the follow-up visit",
          "why": "Booking the follow-up uses the same generic scheduling flow as any recall visit."
        },
        {
          "detail": "Record the home program items given, the follow-up date, and the escalation threshold discussed, in the chart.\n\nRecord: home-care items given, follow-up date, escalation threshold",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Record the home program given"
        },
        {
          "detail": "Conservative management program delivered",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Conservative management program delivered"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "TMD conservative management — self-care, thermal therapy, jaw rest, analgesic plan — TMD is diagnosed without red flags.",
      "title": "TMD conservative management — self-care, thermal therapy, jaw rest, analgesic plan",
      "trigger": "TMD is diagnosed without red flags",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOP orofacial pain guidelines (openly published)",
          "source": "AAOP orofacial pain guidelines (openly published)",
          "url": "https://aaop.org/"
        },
        {
          "kind": "generic",
          "label": "Red-flag screening for non-odontogenic orofacial pain: generic functional equivalent",
          "source": "Red-flag screening for non-odontogenic orofacial pain: generic functional equivalent"
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "otmd-004",
      "kind": "clinical",
      "materials": [
        "referral packet template",
        "phone"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral",
        "ems",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Call 911 and activate EMS immediately, before any further assessment, if the pain pattern includes chest or jaw/arm pain with exertion, sudden severe headache with neurologic deficit, facial droop, or slurred speech — signs of a possible cardiac event or acute neurologic emergency.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 / EMS first if any acute emergency sign is present.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "assistant",
          "title": "Call 911 / EMS first if any acute emergency sign is present"
        },
        {
          "detail": "Dentist weighs the pain pattern for features inconsistent with a dental or muscular source, including whether it includes chest or jaw/arm pain with exertion, sudden severe headache with neurologic deficit, or other acute emergency signs, versus non-emergent red flags such as unexplained numbness, a growing mass, or unexplained weight loss.",
          "forks": [
            {
              "goto": "s10",
              "id": "emergency-signs",
              "label": "Signs suggest a possible cardiac event or acute neurologic emergency"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "non-emergent-red-flags",
              "label": "Red flags present but not acutely emergent"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess whether the pattern includes acute emergency signs"
        },
        {
          "detail": "Dentist confirms the specific red flag(s) present and that they warrant a specialist referral rather than continued dental management, before a referral packet is generated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed review before a specialist referral is generated.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed review before a specialist referral is generated"
        },
        {
          "detail": "Dentist decides whether the pattern points to a likely neurologic origin or a suspected mass/lesion requiring a different specialist.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "neuro",
              "label": "Pattern suggests a neurologic origin"
            },
            {
              "goto": "s14",
              "id": "onc",
              "label": "Pattern suggests a mass or lesion"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Identify the referral target"
        },
        {
          "detail": "Prepare a referral to a neurologist or orofacial pain specialist noting onset, quality, triggers, and exam findings.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare a neurology / orofacial pain referral"
        },
        {
          "detail": "Send the completed referral packet — chart notes, imaging if available, and the red-flag findings — to the receiving specialist and confirm receipt.",
          "id": "s6",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Send the referral packet"
        },
        {
          "detail": "Front desk calls the patient to confirm the referral, explain why it is needed, and provide the specialist's contact information and any urgency guidance given by the dentist.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify the patient of the referral"
        },
        {
          "detail": "Record the red flag(s) identified, the referral target, and the date sent in the chart.\n\nRecord: red flags identified, referral target, date sent",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Record the referral"
        },
        {
          "detail": "Red-flag referral complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Red-flag referral complete"
        },
        {
          "detail": "Call 911 and activate EMS immediately for suspected cardiac event or acute neurologic emergency; do not delay for further dental workup or referral paperwork.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 / activate EMS immediately.",
            "type": "safety"
          },
          "id": "s10",
          "kind": "gate",
          "role": "assistant",
          "title": "Call 911 / activate EMS immediately"
        },
        {
          "detail": "Front desk or clinical staff checks and periodically records the patient's pulse, blood pressure if available, respiration rate, and level of consciousness every few minutes until EMS arrives on scene.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Monitor vitals while awaiting EMS"
        },
        {
          "detail": "Hand the patient off to EMS on arrival with a brief summary of symptom onset, description and any vitals taken.",
          "id": "s12",
          "kind": "step",
          "role": "ems",
          "title": "Hand off to EMS"
        },
        {
          "detail": "Emergency escalation complete",
          "id": "s13",
          "kind": "step",
          "role": "ems",
          "title": "Emergency escalation complete"
        },
        {
          "detail": "Prepare an urgent referral to an oral and maxillofacial surgeon or physician for further workup of a suspected mass or lesion.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare an urgent surgical/medical referral"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Orofacial pain red flags — neurologic, neoplastic or cardiac referral — The pain pattern does not match a dental or muscular source.",
      "title": "Orofacial pain red flags — neurologic, neoplastic or cardiac referral",
      "trigger": "The pain pattern does not match a dental or muscular source",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOP orofacial pain guidelines (openly published)",
          "source": "AAOP orofacial pain guidelines (openly published)",
          "url": "https://aaop.org/"
        },
        {
          "kind": "generic",
          "label": "Stabilization appliance fabrication and delivery workflow — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Stabilization appliance fabrication and delivery workflow: generic functional equivalent"
          },
          "source": "Stabilization appliance fabrication and delivery workflow — Practice policy — no published authority governs this step."
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "otmd-005",
      "kind": "clinical",
      "materials": [
        "impression material or intraoral scanner",
        "bite registration material",
        "lab prescription form",
        "articulating paper",
        "adjustment burs"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison",
        "front-desk",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Dentist confirms the bruxism or TMD diagnosis and that a stabilization appliance is the agreed treatment before records are scheduled.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm diagnosis and appliance plan"
        },
        {
          "detail": "Dentist reviews and approves the appliance type (stabilization/night guard vs anterior deprogrammer) and the arch to be fitted before records are taken.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed review of appliance type before records.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed review of appliance type before records"
        },
        {
          "detail": "Confirm the patient understands and consents to the approved appliance type, the arch to be fitted, and the estimated cost of records and lab fabrication before impressions or scans are taken.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain informed consent to the appliance plan and cost before records.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain informed consent to the appliance plan and cost before records"
        },
        {
          "detail": "Take upper and lower impressions or digital scans, and a bite registration in the dentist-specified relationship (centric relation or habitual bite per the design chosen).",
          "id": "s4",
          "kind": "step",
          "materials": [
            "impression material or intraoral scanner",
            "bite registration material"
          ],
          "role": "assistant",
          "title": "Take impressions/scans and bite registration"
        },
        {
          "detail": "Checklist: material selected (hard acrylic / soft / dual-laminate), thickness, shade, and which arch (maxillary or mandibular) the appliance is for.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Select material, thickness, shade and arch"
        },
        {
          "detail": "Dentist reviews and confirms the assistant's selected appliance material, thickness, shade and arch align with the appliance type approved at the earlier licensed review before the lab prescription is sent.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist confirms selected material and thickness"
        },
        {
          "detail": "Send the records and a written prescription — material, design, arch, adjustment notes — to the fabricating laboratory.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "lab prescription form"
          ],
          "role": "lab-liaison",
          "title": "Send records and prescription to the lab"
        },
        {
          "detail": "Track the case turnaround (typically about 1-2 weeks for a splint lab case, practice- and lab-dependent) and confirm the appliance is received in-house before scheduling the delivery appointment.",
          "id": "s8",
          "kind": "timer",
          "role": "lab-liaison",
          "timer_seconds": 604800,
          "title": "Track the lab case turnaround"
        },
        {
          "detail": "Front desk schedules the delivery appointment once the appliance is confirmed received in-house.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the delivery appointment"
        },
        {
          "detail": "Try the appliance in the mouth and check fit, retention, and seating without rocking or excessive pressure at any point.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Try in the appliance"
        },
        {
          "detail": "Mark with articulating paper and adjust the appliance until even, simultaneous bilateral contacts are achieved with smooth excursive guidance.\n\nWhy: An unbalanced appliance can worsen symptoms instead of relieving them.",
          "id": "s11",
          "kind": "step",
          "materials": [
            "articulating paper",
            "adjustment burs"
          ],
          "role": "dentist",
          "title": "Adjust the appliance occlusion",
          "why": "An unbalanced appliance can worsen symptoms instead of relieving them."
        },
        {
          "detail": "Instruct the patient on the wear schedule (typically nightly), cleaning and storage, and the signs that would warrant an earlier follow-up.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Give wear, cleaning and warning-sign instructions"
        },
        {
          "detail": "Confirm the patient understands and accepts the wear schedule and care instructions and has no remaining questions before leaving the office with the appliance.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient understanding before leaving with the appliance.",
            "type": "safety"
          },
          "id": "s13",
          "kind": "gate",
          "role": "patient",
          "title": "Confirm patient understanding before leaving with the appliance"
        },
        {
          "detail": "Hand off to front desk to schedule the 1, 4 and 12-week follow-ups per the splint follow-up protocol (otmd-006).",
          "id": "s14",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to schedule follow-ups"
        },
        {
          "detail": "Record appliance type, material, delivery date, adjustments made, and the follow-up schedule in the chart.\n\nRecord: appliance type, material, delivery date, adjustments made, follow-up schedule",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Record the delivery"
        },
        {
          "detail": "Appliance delivered",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Appliance delivered"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Occlusal splint or night guard — records, design, delivery and adjustment — Bruxism or TMD is diagnosed and a stabilization appliance is planned.",
      "title": "Occlusal splint or night guard — records, design, delivery and adjustment",
      "trigger": "Bruxism or TMD is diagnosed and a stabilization appliance is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOP orofacial pain guidelines (openly published)",
          "source": "AAOP orofacial pain guidelines (openly published)",
          "url": "https://aaop.org/"
        },
        {
          "kind": "generic",
          "label": "Staged appliance follow-up interval (1, 4, 12 weeks) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Staged appliance follow-up interval (1, 4, 12 weeks): generic functional equivalent"
          },
          "source": "Staged appliance follow-up interval (1, 4, 12 weeks) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "otmd-006",
      "kind": "clinical",
      "materials": [
        "articulating paper",
        "adjustment burs"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Assistant asks the patient how many nights per week the appliance was worn since delivery or the last visit, and notes any reported discomfort, breakage, or fit change.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Check wear compliance"
        },
        {
          "detail": "Checklist: retention in the mouth, cracks or fractures, wear-through marks on the occlusal surface, and whether the marked contacts are still even.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Inspect the appliance"
        },
        {
          "detail": "Ask about jaw pain, headaches, clicking or locking, and tooth sensitivity changes since the last visit.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check symptom status"
        },
        {
          "detail": "Dentist decides, from the inspection and symptom check, whether the appliance needs an occlusal adjustment today.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "adjust-needed",
              "label": "Contacts have shifted or symptoms persist"
            },
            {
              "goto": "s7",
              "id": "no-adjustment",
              "label": "Appliance fits well and symptoms are improving"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether an adjustment is needed"
        },
        {
          "detail": "Dentist confirms the specific adjustment needed — grinding a high spot, relining, or remaking — before altering the appliance.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before altering the appliance.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before altering the appliance"
        },
        {
          "detail": "Mark with articulating paper and selectively adjust the appliance to restore even bilateral contact.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "articulating paper",
            "adjustment burs"
          ],
          "role": "dentist",
          "title": "Adjust the appliance"
        },
        {
          "detail": "Dentist decides whether to proceed to the next scheduled interval or, if symptoms remain unresolved at 12 weeks, to reassess the diagnosis.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "continue-schedule",
              "label": "Proceed to the next scheduled interval (1→4wk, 4→12wk) or close out at 12 weeks"
            },
            {
              "goto": "s11",
              "id": "extend-monitoring",
              "label": "Symptoms unresolved at 12 weeks — reassess the diagnosis"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm the next step in the follow-up schedule"
        },
        {
          "detail": "Front desk books the next interval follow-up (4-week or 12-week) or, if 12-week review is complete and stable, folds the appliance check into the routine recall cycle.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the next interval or close out"
        },
        {
          "detail": "Record wear compliance, inspection findings, symptom status, any adjustment made, and the next interval in the chart.\n\nRecord: wear compliance, inspection findings, symptom status, adjustment made, next interval",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Record the follow-up visit"
        },
        {
          "detail": "Follow-up interval complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Follow-up interval complete"
        },
        {
          "detail": "Hand off to the TMD screening protocol (otmd-002) to reassess the diagnosis when symptoms remain unresolved at the 12-week mark.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to TMD reassessment"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Splint follow-up — 1, 4 and 12-week adjustment and wear review — The appliance was delivered and follow-ups are due.",
      "title": "Splint follow-up — 1, 4 and 12-week adjustment and wear review",
      "trigger": "The appliance was delivered and follow-ups are due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Standard selective-grinding sequence (nonworking interferences, then working-side interferences, then centric prematurities) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Standard selective-grinding sequence (nonworking interferences, then working-side interferences, then centric prematurities): generic functional equivalent"
          },
          "source": "Standard selective-grinding sequence (nonworking interferences, then working-side interferences, then centric prematurities) — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "source": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "url": "https://ubwp.buffalo.edu/rdc-tmdinternational/"
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "otmd-007",
      "kind": "clinical",
      "materials": [
        "articulating paper (two colors)",
        "adjustment burs",
        "polishing points/discs"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Dentist identifies the specific premature contact or interference reported — a new restoration high spot, a shifted tooth, or a symptomatic natural tooth — via patient report and clinical exam.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the reported interference"
        },
        {
          "detail": "Dentist confirms the diagnosis of a true interference (not a reversible adaptation period) and that selective grinding — an irreversible removal of tooth structure — is indicated, before any adjustment is made.\n\nWhy: Grinding tooth structure cannot be undone; confirming the diagnosis first prevents an unnecessary or wrong-site adjustment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed confirmation before an irreversible adjustment.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed confirmation before an irreversible adjustment",
          "why": "Grinding tooth structure cannot be undone; confirming the diagnosis first prevents an unnecessary or wrong-site adjustment."
        },
        {
          "detail": "Explain to the patient that a small amount of tooth structure will be selectively adjusted and obtain verbal consent before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain patient consent for the adjustment.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain patient consent for the adjustment"
        },
        {
          "detail": "Have the patient close in centric occlusion/relation with one color of articulating paper to mark simultaneous contacts.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "articulating paper (two colors)"
          ],
          "role": "dentist",
          "title": "Mark centric contacts"
        },
        {
          "detail": "Re-mark with a second color during lateral and protrusive excursions to distinguish excursive interferences from centric contacts.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Mark excursive contacts"
        },
        {
          "detail": "Follow the standard sequence: reduce non-working (balancing) interferences first, then working-side interferences, then centric prematurities, re-checking marks between each step.\n\nWhy: This sequence is the standard method to avoid over-reducing and creating a new interference elsewhere.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Follow the selective-grinding sequence",
          "why": "This sequence is the standard method to avoid over-reducing and creating a new interference elsewhere."
        },
        {
          "detail": "Re-mark and re-check for even, simultaneous bilateral centric contacts and smooth excursive guidance after adjustment.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Re-verify contacts"
        },
        {
          "detail": "Polish all adjusted enamel surfaces to restore a smooth finish.\n\nWhy: An unpolished adjustment surface can roughen, re-attract plaque, or feel rough to the tongue.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "polishing points/discs"
          ],
          "role": "assistant",
          "title": "Polish adjusted surfaces",
          "why": "An unpolished adjustment surface can roughen, re-attract plaque, or feel rough to the tongue."
        },
        {
          "detail": "Confirm with the patient that the bite feels even and comfortable, with no new high spots noticed.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm patient comfort"
        },
        {
          "detail": "Record which teeth and surfaces were adjusted, the sequence followed, and the amount of tooth structure removed (minimal/moderate) in the chart.\n\nRecord: teeth/surfaces adjusted, sequence followed, amount removed",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Record the adjustment"
        },
        {
          "detail": "Occlusal adjustment complete",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Occlusal adjustment complete"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Occlusal adjustment (selective grinding) with marking sequence — A premature contact or interference is causing symptoms or restoration failure.",
      "title": "Occlusal adjustment (selective grinding) with marking sequence",
      "trigger": "A premature contact or interference is causing symptoms or restoration failure",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "source": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "url": "https://ubwp.buffalo.edu/rdc-tmdinternational/"
        },
        {
          "kind": "generic",
          "label": "Manual reduction (bimanual technique) for acute open lock and conservative management for acute closed lock — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Manual reduction (bimanual technique) for acute open lock and conservative management for acute closed lock: generic functional equivalent"
          },
          "source": "Manual reduction (bimanual technique) for acute open lock and conservative management for acute closed lock — Practice policy — no published authority governs this step."
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "otmd-008",
      "kind": "clinical",
      "materials": [
        "gauze/gloves for thumb protection during reduction",
        "jaw support wrap",
        "phone for 911/EMS or urgent referral"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "ems",
        "specialist-referral",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the patient shows signs of airway compromise, severe trauma, or cannot be safely managed in-office, call 911/EMS immediately before attempting any in-office maneuver.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 / EMS if this is not manageable in-office.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "assistant",
          "title": "Call 911 / EMS if this is not manageable in-office"
        },
        {
          "detail": "Dentist assesses whether the patient cannot close the mouth (jaw locked open, often after a wide yawn) or cannot open beyond a limited range (acute closed lock).",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "open-lock",
              "label": "Cannot close — jaw locked open"
            },
            {
              "goto": "s10",
              "id": "closed-lock",
              "label": "Cannot open beyond a limited range"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess open lock vs closed lock"
        },
        {
          "detail": "Position the patient upright, explain the reduction maneuver, and prepare to attempt manual reduction (bimanual technique — thumbs on the mandibular molars, downward and posterior pressure) as first-line conservative management.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "gauze/gloves for thumb protection"
          ],
          "role": "dentist",
          "title": "Prepare for manual reduction"
        },
        {
          "detail": "Explain the reduction maneuver and obtain verbal consent (or caregiver consent for a minor or dependent adult) before attempting it, including that some discomfort is expected.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain consent for the reduction maneuver.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain consent for the reduction maneuver"
        },
        {
          "detail": "Perform the manual reduction maneuver and reassess whether the mandible has relocated after each attempt, limiting the number of attempts to avoid patient distress or muscle spasm.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Attempt the manual reduction"
        },
        {
          "detail": "Dentist assesses whether the jaw relocated and the patient can close normally, or whether reduction was unsuccessful or the patient is in significant distress.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "successful",
              "label": "Jaw relocated and patient can close normally"
            },
            {
              "goto": "s13",
              "id": "unsuccessful",
              "label": "Unable to reduce, or patient in significant distress"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess the reduction outcome"
        },
        {
          "detail": "Advise a soft diet, avoidance of wide opening or yawning, and a jaw support wrap if tolerated, for several days; schedule a follow-up visit.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "jaw support wrap"
          ],
          "role": "dentist",
          "title": "Give post-reduction care instructions"
        },
        {
          "detail": "Record the lock type, the maneuver or management used, the outcome, and the follow-up plan in the chart.\n\nRecord: lock type, maneuver/management used, outcome, follow-up plan",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Record the lock event and outcome"
        },
        {
          "detail": "Acute jaw lock event closed out",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Acute jaw lock event closed out"
        },
        {
          "detail": "Assess for a suspected displaced disc without reduction (limited opening, deviation toward the affected side); avoid forceful manipulation and manage conservatively in-office.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Assess suspected closed lock"
        },
        {
          "detail": "Dentist decides whether the closed lock is mild-to-moderate and tolerable, or severe with significant pain or trismus and no improvement.",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "manageable",
              "label": "Mild-moderate limitation, tolerable pain"
            },
            {
              "goto": "s13",
              "id": "severe",
              "label": "Severe pain, significant trismus, or no improvement"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess closed-lock severity"
        },
        {
          "detail": "Apply moist heat, advise a soft diet, and gentle passive stretching within a pain-free range, and schedule a close follow-up per the conservative TMD management protocol (otmd-003).",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Manage the closed lock conservatively"
        },
        {
          "detail": "Arrange an urgent same-day referral to an oral and maxillofacial surgeon, or the emergency department if unavailable, for reduction under sedation.",
          "id": "s13",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Refer urgently for reduction under sedation"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Acute open lock (dislocation) or closed lock management — A patient cannot close or cannot open the mouth after a wide yawn or procedure.",
      "title": "Acute open lock (dislocation) or closed lock management",
      "trigger": "A patient cannot close or cannot open the mouth after a wide yawn or procedure",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOP orofacial pain guidelines (openly published)",
          "source": "AAOP orofacial pain guidelines (openly published)",
          "url": "https://aaop.org/"
        },
        {
          "kind": "open_standard",
          "label": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "source": "Diagnostic Criteria for TMD (DC/TMD) — openly published",
          "url": "https://ubwp.buffalo.edu/rdc-tmdinternational/"
        },
        {
          "kind": "open_standard",
          "label": "STOP-BANG and similar validated sleep-screening questionnaires — openly published instruments",
          "source": "STOP-BANG and similar validated sleep-screening questionnaires — openly published instruments"
        },
        {
          "kind": "generic",
          "label": "Bruxism/airway cross-screen intake and referral workflow: — no single public standard mandates the office workflow itself, only the underlying screening tools — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Bruxism/airway cross-screen intake and referral workflow: generic functional equivalent — no single public standard mandates the office workflow itself, only the underlying screening tools"
          },
          "source": "Bruxism/airway cross-screen intake and referral workflow: — no single public standard mandates the office workflow itself, only the underlying screening tools — Practice policy — no published authority governs this step."
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "per-patient",
      "id": "otmd-009",
      "kind": "clinical",
      "materials": [
        "intraoral mirror and explorer",
        "wear-facet photo/exam form",
        "validated sleep-screening questionnaire (e.g. STOP-BANG or similar)",
        "bruxism history form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "During the routine exam, check for flattened cusps, enamel wear facets, tongue scalloping, cheek ridging (linea alba), and masseter hypertrophy; note location and severity.\n\nWhy: These are the physical fingerprints of parafunctional grinding and are often found before a patient reports any symptom.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Examine for wear facets and grinding signs at hygiene visit",
          "why": "These are the physical fingerprints of parafunctional grinding and are often found before a patient reports any symptom."
        },
        {
          "detail": "Ask whether the patient or a bed partner notices grinding/clenching at night, morning jaw soreness or headaches, daytime jaw clenching, snoring, witnessed pauses in breathing, or daytime sleepiness.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Take a brief bruxism and sleep history"
        },
        {
          "detail": "Decide whether findings support further screening or the visit continues as routine hygiene.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "positive",
              "label": "Yes — wear facets or reported grinding present"
            },
            {
              "goto": "s11",
              "id": "negative",
              "label": "No — no wear or grinding reported"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "hygienist",
          "title": "Are wear facets or a positive bruxism history present?"
        },
        {
          "detail": "Have the patient complete a validated instrument such as STOP-BANG (snoring, tiredness, observed apnea, blood pressure, BMI, age, neck size, gender) to flag airway-related risk factors.\n\nWhy: Bruxism has a documented association with sleep-disordered breathing in the open literature; a positive screen changes the referral path from purely dental to a joint dental/medical workup.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Administer a validated sleep-screening questionnaire",
          "why": "Bruxism has a documented association with sleep-disordered breathing in the open literature; a positive screen changes the referral path from purely dental to a joint dental/medical workup."
        },
        {
          "detail": "Dentist examines the noted wear facets directly, correlates with the questionnaire score, and determines whether this is likely isolated dental bruxism or bruxism with a probable airway component.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews wear findings and screening result"
        },
        {
          "detail": "Dentist confirms the diagnosis note and decides between conservative dental management alone versus a sleep-medicine referral before anything is documented as a clinical finding or communicated to the patient.\n\nWhy: Diagnosis and referral direction are licensed clinical judgments that must not be finalized by front-line screening staff alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on assessment and next step.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on assessment and next step",
          "why": "Diagnosis and referral direction are licensed clinical judgments that must not be finalized by front-line screening staff alone."
        },
        {
          "detail": "Decide whether the questionnaire score and clinical picture warrant referring the patient for a sleep-medicine evaluation.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "refer",
              "label": "Yes — refer to sleep medicine for evaluation"
            },
            {
              "goto": "s13",
              "id": "dental-only",
              "label": "No — manage as isolated dental bruxism"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the sleep screen support a referral?"
        },
        {
          "detail": "Prepare a referral letter summarizing wear findings and screening score and send to a sleep-medicine provider or the patient's physician for evaluation.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to sleep medicine"
        },
        {
          "detail": "Chart the wear-facet findings, sleep-screen score, diagnosis note, and whether a referral was made or dental-only management was chosen.\n\nRecord: wear findings, sleep-screen score, referral status logged in chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document assessment, screen result and referral status"
        },
        {
          "detail": "Bruxism assessment and cross-screen complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Bruxism assessment and cross-screen complete"
        },
        {
          "detail": "Note in the chart that no bruxism or wear findings were present at this visit.\n\nRecord: negative bruxism/wear screen noted in chart",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Document negative screen and continue routine care"
        },
        {
          "detail": "Routine hygiene visit continues, no further action",
          "id": "s12",
          "kind": "step",
          "role": "hygienist",
          "title": "Routine hygiene visit continues, no further action"
        },
        {
          "detail": "Discuss protective options (e.g. an occlusal guard per the splint-delivery protocol, otmd-005) and self-care measures with the patient; schedule follow-up.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Begin conservative dental bruxism management"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Bruxism assessment with sleep-disordered-breathing cross-screen — Wear facets or reported grinding; an airway contribution must be ruled out.",
      "title": "Bruxism assessment with sleep-disordered-breathing cross-screen",
      "trigger": "Wear facets or reported grinding; an airway contribution must be ruled out",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAOP orofacial pain guidelines (openly published)",
          "source": "AAOP orofacial pain guidelines (openly published)",
          "url": "https://aaop.org/"
        },
        {
          "kind": "generic",
          "label": "Comprehensive occlusal treatment-planning worksheets — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Comprehensive occlusal treatment-planning worksheets — generic functional equivalent only"
          },
          "source": "Comprehensive occlusal treatment-planning worksheets — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Full-mouth rehabilitation staging (records → diagnostic wax-up → provisional trial → definitive restoration) is a widely published, non-proprietary clinical sequence; no single named body owns it — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Full-mouth rehabilitation staging (records → diagnostic wax-up → provisional trial → definitive restoration) is a widely published, non-proprietary clinical sequence; no single named body owns it"
          },
          "source": "Full-mouth rehabilitation staging (records → diagnostic wax-up → provisional trial → definitive restoration) is a widely published, non-proprietary clinical sequence; no single named body owns it — Practice policy — no published authority governs this step."
        }
      ],
      "class": "tmd-orofacial-pain",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "otmd-010",
      "kind": "clinical",
      "materials": [
        "facebow / articulator records",
        "diagnostic wax-up or digital mock-up",
        "provisional materials",
        "photographic and radiographic records",
        "treatment-planning worksheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "lab-liaison",
        "treatment-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Collect full-mouth photographs, panoramic and periapical radiographs (or CBCT if indicated), facebow-mounted study models or a digital equivalent, and a written chief-complaint/goals summary.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Gather comprehensive diagnostic records"
        },
        {
          "detail": "Evaluate the extent of wear or collapse, measure available restorative space, and determine whether an increase in vertical dimension is needed to restore form and function.\n\nWhy: Whether and how much vertical dimension changes drives every downstream planning decision — provisional design, staging, and material selection.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Assess current vertical dimension of occlusion and wear pattern",
          "why": "Whether and how much vertical dimension changes drives every downstream planning decision — provisional design, staging, and material selection."
        },
        {
          "detail": "Decide the treatment approach based on the wear/collapse assessment.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "increase-vdo",
              "label": "Yes — plan a vertical dimension increase"
            },
            {
              "goto": "s4",
              "id": "same-vdo",
              "label": "No — restore at existing vertical dimension"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Will vertical dimension be increased?"
        },
        {
          "detail": "Send the mounted records and the dentist's planned vertical-dimension and tooth-form notes to the lab for a diagnostic wax-up (physical or digital).\n\nWhy: The wax-up lets the whole team and the patient see and test the plan before any tooth structure is committed.",
          "id": "s4",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send records to the lab for a diagnostic wax-up or digital mock-up",
          "why": "The wax-up lets the whole team and the patient see and test the plan before any tooth structure is committed."
        },
        {
          "detail": "Evaluate the wax-up for esthetics, function, and phonetics; request revisions from the lab if needed.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Review the wax-up and refine the plan"
        },
        {
          "detail": "Present the mock-up (photos, models, or a chairside try-in) alongside a written treatment plan, stages, and cost estimate; answer questions and record the patient's decision.",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the case and cost estimate to the patient"
        },
        {
          "detail": "Confirm whether the patient accepted the treatment plan and financial terms.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "accepted",
              "label": "Yes — proceed to patient consent"
            },
            {
              "goto": "s15",
              "id": "not-accepted",
              "label": "No — plan declined or deferred"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "Did the patient accept the plan?"
        },
        {
          "detail": "Confirm the patient's informed consent to the treatment plan, the vertical-dimension change, cost, and alternatives discussed, before the dentist's final clinical sign-off commits the case to preparation.\n\nWhy: Patient consent must be secured before, not after, the dentist clinically commits to an irreversible plan.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain patient informed consent before the dentist's final sign-off.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain patient informed consent before the dentist's final sign-off",
          "why": "Patient consent must be secured before, not after, the dentist clinically commits to an irreversible plan."
        },
        {
          "detail": "Dentist reviews and signs off on the final treatment plan, vertical-dimension change, and staging sequence before any tooth preparation or provisional fabrication begins.\n\nWhy: Committing to a vertical-dimension change and tooth preparation is irreversible chairside; this is the last checkpoint before that commitment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before provisional fabrication begins.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before provisional fabrication begins",
          "why": "Committing to a vertical-dimension change and tooth preparation is irreversible chairside; this is the last checkpoint before that commitment."
        },
        {
          "detail": "Prepare and provisionalize the arch (in segments or as a full arch depending on the staging plan) at the new vertical dimension and tooth form approved in the mock-up.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Fabricate and deliver a full-arch or segmental provisional at the planned vertical dimension"
        },
        {
          "detail": "Have the patient wear the provisional restoration for a trial period (commonly 2–4 weeks, practice-set) to confirm comfort, function, speech, and esthetics at the new vertical dimension before finalizing.\n\nWhy: A trial period at the new vertical dimension catches muscular or TMJ intolerance before it is locked into definitive, harder-to-adjust restorations.",
          "id": "s11",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 1814400,
          "title": "Provisional trial period",
          "why": "A trial period at the new vertical dimension catches muscular or TMJ intolerance before it is locked into definitive, harder-to-adjust restorations."
        },
        {
          "detail": "Reassess jaw comfort, muscle symptoms, occlusal contacts, and patient feedback after the trial period; adjust the provisional if needed before proceeding to definitive restorations.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Review provisional trial outcome"
        },
        {
          "detail": "Chart the accepted vertical-dimension change, staging sequence, provisional trial findings, and readiness to proceed to definitive restorations.\n\nRecord: vertical-dimension change, staging plan, and provisional trial outcome logged in chart",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the finalized rehabilitation plan and provisional outcome"
        },
        {
          "detail": "Occlusal planning and provisional phase complete; case ready for definitive restorative phase",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Occlusal planning and provisional phase complete; case ready for definitive restorative phase"
        },
        {
          "detail": "Log the presented plan, cost, and the patient's reason for declining or deferring, for future reference.\n\nRecord: declined/deferred plan and reason logged in chart",
          "id": "s15",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the declined or deferred plan"
        },
        {
          "detail": "Case declined or deferred, planning cycle ends",
          "id": "s16",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Case declined or deferred, planning cycle ends"
        }
      ],
      "subclass": "occlusion-tmd-and-orofacial-pain",
      "summary": "Full-mouth rehabilitation — occlusal planning, vertical dimension change, mock-up and staging — Generalized wear or collapse where the vertical dimension must be restored.",
      "title": "Full-mouth rehabilitation — occlusal planning, vertical dimension change, mock-up and staging",
      "trigger": "Generalized wear or collapse where the vertical dimension must be restored",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard KPI set (production, collection %) reconciled at daily close — no analytics vendor reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard KPI set (production, collection %) reconciled at daily close — no analytics vendor reproduced"
          },
          "source": ": standard KPI set (production, collection %) reconciled at daily close — no analytics vendor reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 15,
      "frequency": "daily",
      "id": "own-001",
      "kind": "operational",
      "materials": [
        "practice management system daily report",
        "credit card terminal batch summary",
        "deposit slip",
        "cash drawer count sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "At close of the clinical day, run the practice management system's daily report showing scheduled production, completed production, and total collections (cash, check, card, and any online payments) for every provider who saw patients.\n\nWhy: The report is the single source that reconciles what was scheduled, delivered, and paid — catching same-day gaps before they compound.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the day's production and collection report",
          "why": "The report is the single source that reconciles what was scheduled, delivered, and paid — catching same-day gaps before they compound."
        },
        {
          "detail": "Compare the report's completed-production figure to the day's schedule: every completed appointment should show a charge; every no-show or same-day cancellation should show zero and a coded reason.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify production totals against the schedule"
        },
        {
          "detail": "Add cash counted in the drawer, the card terminal batch total, check deposits, and any online payments; this sum must equal the report's total-collections line.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Verify collections against payment sources"
        },
        {
          "detail": "Do production and collections reconcile?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "match",
              "label": "Totals match, no discrepancy"
            },
            {
              "goto": "s8",
              "id": "variance",
              "label": "A variance exists (missing charge, drawer short, unposted payment)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Do production and collections reconcile?"
        },
        {
          "detail": "File the signed daily report as reviewed-and-balanced for the date; this becomes the source record for the weekly scorecard.\n\nRecord: Daily report reviewed/balanced status, reviewer initials, date",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the daily report as reconciled"
        },
        {
          "detail": "Any charge that could not be reconciled same-day (pending insurance estimate, disputed card decline, missing signature) is added to billing's next-day worklist with the amount and reason.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off unresolved items to billing"
        },
        {
          "detail": "Daily close complete",
          "id": "s7",
          "kind": "step",
          "title": "Daily close complete"
        },
        {
          "detail": "Trace the mismatch line by line: check for an unposted payment, a charge entered under the wrong provider or patient, or a drawer-count error; correct the entry or note the unresolved amount and reason.\n\nWhy: An undocumented variance is the exact gap the monthly audit-trail review is built to catch retroactively — closing it same-day is cheaper and cleaner.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Investigate and document the variance",
          "why": "An undocumented variance is the exact gap the monthly audit-trail review is built to catch retroactively — closing it same-day is cheaper and cleaner."
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "End-of-day production and collection report review — End of every clinical day.",
      "title": "End-of-day production and collection report review",
      "trigger": "End of every clinical day",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced"
          },
          "source": ": standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "weekly",
      "id": "own-002",
      "kind": "operational",
      "materials": [
        "prior week's daily reports",
        "scheduling system report",
        "case acceptance log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull the seven daily reports since the last scorecard and total production, collections, new-patient count, reappointment rate, case-acceptance rate, no-show rate, and accounts-receivable aging over 90 days.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the week's daily reports into the scorecard"
        },
        {
          "detail": "For each metric compute the week's value and compare it to the practice's target range; flag any metric outside its band.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Calculate each KPI against its target band"
        },
        {
          "detail": "Any KPI outside its target band?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean",
              "label": "All KPIs within band"
            },
            {
              "goto": "s7",
              "id": "flag",
              "label": "One or more KPIs out of band"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Any KPI outside its target band?"
        },
        {
          "detail": "Post the week's scorecard with aggregate numbers only, no patient identifiers, where the team can see it before the meeting.\n\nRecord: Weekly KPI values, target-band status, publish date",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Publish the clean scorecard"
        },
        {
          "detail": "The office manager or practice owner walks the team through the week's numbers, calls out wins, and names the one or two metrics being worked on.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Present the scorecard at the team meeting"
        },
        {
          "detail": "Weekly scorecard cycle complete",
          "id": "s6",
          "kind": "step",
          "title": "Weekly scorecard cycle complete"
        },
        {
          "detail": "Note which metric(s) moved outside the target band and route them into the KPI anomaly investigation protocol rather than guessing at a cause during the scorecard step.\n\nWhy: Anomaly investigation needs its own root-cause pass; folding it into the weekly compile step produces rushed, unreliable explanations.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag out-of-band metrics for the anomaly investigation protocol",
          "why": "Anomaly investigation needs its own root-cause pass; folding it into the weekly compile step produces rushed, unreliable explanations."
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Weekly KPI scorecard — Weekly, before the team meeting.",
      "title": "Weekly KPI scorecard",
      "trigger": "Weekly, before the team meeting",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard overhead-category review (staff, lab/supplies, occupancy, marketing) against published benchmark ranges — no vendor benchmark tool reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard overhead-category review (staff, lab/supplies, occupancy, marketing) against published benchmark ranges — no vendor benchmark tool reproduced"
          },
          "source": ": standard overhead-category review (staff, lab/supplies, occupancy, marketing) against published benchmark ranges — no vendor benchmark tool reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Internal-control principles (segregation of duties, timely reconciliation) — generic accounting practice",
          "source": "Internal-control principles (segregation of duties, timely reconciliation) — generic accounting practice"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "own-003",
      "kind": "operational",
      "materials": [
        "monthly profit and loss statement",
        "overhead category breakdown",
        "prior-month P&L for comparison",
        "overhead benchmark reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the bookkeeper has closed the books for the month (all bills entered, bank and card accounts reconciled, payroll posted) before reviewing the P&L.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the closed month-end P&L from the bookkeeper or accountant"
        },
        {
          "detail": "Group expenses into staff cost, lab/supplies, facility/occupancy, marketing, and other overhead; compute each as a percentage of collections.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Break overhead into standard categories"
        },
        {
          "detail": "Line up this month's overhead percentages against the practice's target ranges and against the prior month; note any category that moved more than a few points.\n\nWhy: A category that jumps outside its normal range is usually the fastest signal of a billing error, a rate change, or a new recurring cost that needs a decision.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Compare each category to the practice's benchmark range",
          "why": "A category that jumps outside its normal range is usually the fastest signal of a billing error, a rate change, or a new recurring cost that needs a decision."
        },
        {
          "detail": "Is overhead within the expected range?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "ok",
              "label": "Overhead within range, no action needed"
            },
            {
              "goto": "s7",
              "id": "out",
              "label": "One or more categories out of range"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is overhead within the expected range?"
        },
        {
          "detail": "Note the review date, reviewer, and 'within range' conclusion on the P&L; file with the month's financial packet.\n\nRecord: P&L review date, reviewer, conclusion",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "File the reviewed P&L"
        },
        {
          "detail": "Monthly P&L review complete",
          "id": "s6",
          "kind": "step",
          "title": "Monthly P&L review complete"
        },
        {
          "detail": "Walk the flagged category line by line with the bookkeeper to identify the driver (one-time expense, rate increase, miscategorized entry) before deciding on a corrective action.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Discuss the out-of-range category with the bookkeeper or accountant"
        },
        {
          "detail": "Record what caused the variance and what, if anything, changes going forward (renegotiate a vendor, recategorize an expense, adjust a budget line).\n\nRecord: Variance cause, corrective action, date",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Document the finding and any corrective action"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Monthly P&L and overhead review with the bookkeeper or accountant — Month-end books are closed.",
      "title": "Monthly P&L and overhead review with the bookkeeper or accountant",
      "trigger": "Month-end books are closed",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Internal-control principles (segregation of duties, owner review of adjustments/refunds/deletions as an embezzlement control) — generic accounting/internal-audit practice",
          "source": "Internal-control principles (segregation of duties, owner review of adjustments/refunds/deletions as an embezzlement control) — generic accounting/internal-audit practice"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 45,
      "frequency": "monthly",
      "id": "own-004",
      "kind": "operational",
      "materials": [
        "practice management system adjustment report",
        "refund report",
        "deleted/voided transaction report",
        "bank deposit records"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Run the practice management system's report of every adjustment, refund, void, and deleted transaction for the month, including which staff login made each entry.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the full adjustment, refund, and deletion report"
        },
        {
          "detail": "Compare the bank's deposit records line by line to the system's posted-collections report for the same period to confirm every dollar collected was deposited.\n\nWhy: This is the classic embezzlement pattern — collections posted but not deposited, or deposited but never posted — and it is only caught by comparing the two independent records.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Reconcile deposits against posted collections",
          "why": "This is the classic embezzlement pattern — collections posted but not deposited, or deposited but never posted — and it is only caught by comparing the two independent records."
        },
        {
          "detail": "The owner, not the person who processes daily transactions, reads every adjustment and refund line: amount, reason code, patient account, and staff member who entered it.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the adjustment and refund list personally"
        },
        {
          "detail": "Does every entry have a documented, legitimate reason?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "clean",
              "label": "All entries documented and legitimate"
            },
            {
              "goto": "s7",
              "id": "unexplained",
              "label": "One or more entries are unexplained or the pattern looks unusual"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does every entry have a documented, legitimate reason?"
        },
        {
          "detail": "Owner initials and dates the reviewed reports; file with the month's financial packet as the completed embezzlement-control check.\n\nRecord: Owner sign-off, date, no-exceptions note",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Sign off the month's audit-trail review"
        },
        {
          "detail": "Audit-trail review complete",
          "id": "s6",
          "kind": "step",
          "title": "Audit-trail review complete"
        },
        {
          "detail": "Before raising the finding with the staff member involved, contacting a bookkeeper or accountant for a deeper look, or considering a report to authorities, the practice owner personally reviews the specific transactions and decides the next step — this step is never delegated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before any staff-facing or escalation action.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before any staff-facing or escalation action"
        },
        {
          "detail": "Pull the underlying documentation for the flagged entries (visit notes, patient communication, receipt copies) and, if needed, have the bookkeeper or accountant independently trace the transactions.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Investigate the unexplained pattern"
        },
        {
          "detail": "Record what was found, whether it was an honest error or requires further action (policy change, staff conversation, external referral), and the date resolved.\n\nRecord: Investigation notes, resolution, date",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Document findings and resolution"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Monthly adjustments, deletions, refunds and audit-trail review (embezzlement control) — Monthly — the owner personally reviews adjustment, refund and deletion reports and deposit reconciliation.",
      "title": "Monthly adjustments, deletions, refunds and audit-trail review (embezzlement control)",
      "trigger": "Monthly — the owner personally reviews adjustment, refund and deletion reports and deposit reconciliation",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard provider-productivity and hygiene-to-doctor production ratio tracking — no vendor analytics dashboard reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard provider-productivity and hygiene-to-doctor production ratio tracking — no vendor analytics dashboard reproduced"
          },
          "source": ": standard provider-productivity and hygiene-to-doctor production ratio tracking — no vendor analytics dashboard reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "own-005",
      "kind": "operational",
      "materials": [
        "monthly production-by-provider report",
        "hygiene department production report",
        "provider goal sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Break the month's total production down by each dentist and hygienist, including hours scheduled and hours worked.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull production by provider for the month"
        },
        {
          "detail": "Divide hygiene department production by doctor production to get the ratio, and compute production-per-hour for each provider.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Calculate the hygiene-to-doctor production ratio"
        },
        {
          "detail": "Line up each provider's production and ratio against the individual goal set at the last quarterly review.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Compare each provider to their goal"
        },
        {
          "detail": "Is every provider tracking to goal?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "on-track",
              "label": "All providers on track"
            },
            {
              "goto": "s7",
              "id": "below",
              "label": "One or more providers below goal"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is every provider tracking to goal?"
        },
        {
          "detail": "Note the review date and 'on track' conclusion; file with the month's KPI packet.\n\nRecord: Review date, on-track conclusion",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "File the productivity review as on-track"
        },
        {
          "detail": "Provider productivity review complete",
          "id": "s6",
          "kind": "step",
          "title": "Provider productivity review complete"
        },
        {
          "detail": "Discuss the gap directly with the provider — schedule utilization, case acceptance, or an external factor such as leave or ramp-up — before assuming a performance issue.\n\nWhy: Production shortfalls have many causes besides effort; a direct conversation avoids misreading a scheduling or referral problem as a personal one.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Have a private conversation with the provider below goal",
          "why": "Production shortfalls have many causes besides effort; a direct conversation avoids misreading a scheduling or referral problem as a personal one."
        },
        {
          "detail": "Record what was discussed and any agreed next step (schedule adjustment, coaching, revisit next month).\n\nRecord: Conversation summary, follow-up plan, date",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Document the conversation and any follow-up plan"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Provider productivity and hygiene-ratio review — The monthly production report is closed and provider and hygiene columns are compared to goal.",
      "title": "Provider productivity and hygiene-ratio review",
      "trigger": "The monthly production report is closed and provider and hygiene columns are compared to goal",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard KPI variance investigation (compare to trailing average, isolate cause, verify fix) — no vendor anomaly-detection tool reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard KPI variance investigation (compare to trailing average, isolate cause, verify fix) — no vendor anomaly-detection tool reproduced"
          },
          "source": ": standard KPI variance investigation (compare to trailing average, isolate cause, verify fix) — no vendor anomaly-detection tool reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "own-006",
      "kind": "operational",
      "materials": [
        "weekly/monthly scorecard history",
        "daily reports for the affected period",
        "scheduling system logs"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Re-pull the metric from source data and recompute it by hand before investigating further — a formula or data-entry error in the report itself is the most common false alarm.\n\nWhy: Chasing a root cause for a number that was never actually true wastes the whole team's time.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the anomaly is real, not a reporting error",
          "why": "Chasing a root cause for a number that was never actually true wastes the whole team's time."
        },
        {
          "detail": "Does the recomputed number confirm the anomaly?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "confirmed",
              "label": "Anomaly confirmed"
            },
            {
              "goto": "s9",
              "id": "reporting-error",
              "label": "It was a reporting or calculation error"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the recomputed number confirm the anomaly?"
        },
        {
          "detail": "Look at the metric over the prior 4-8 periods to see whether this is a one-time blip, a trend, or a step change tied to a specific date.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Compare the affected period against the trailing average"
        },
        {
          "detail": "For production/collection drops: check for provider absence, a schedule gap, an insurance processing delay, or a system outage. For no-show spikes: check for a holiday, weather, or a broken reminder system. For AR spikes: check for a claim-processing change or a large unpaid balance.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the usual root causes for this metric"
        },
        {
          "detail": "Was a clear cause identified?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "found",
              "label": "Cause identified"
            },
            {
              "goto": "s10",
              "id": "unclear",
              "label": "No clear cause found"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Was a clear cause identified?"
        },
        {
          "detail": "Decide whether the identified cause needs a process, staffing, or scheduling change, or whether it was a one-time event that needs no change.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Assess whether a corrective change is needed"
        },
        {
          "detail": "Record the cause, or 'unresolved, monitoring', any corrective action, and the date, so the next anomaly on this metric has a reference point.\n\nRecord: Root cause, corrective action, date",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the investigation and any action taken"
        },
        {
          "detail": "Anomaly investigation complete",
          "id": "s8",
          "kind": "step",
          "title": "Anomaly investigation complete"
        },
        {
          "detail": "Fix the underlying report error and note in the KPI log that the anomaly was a reporting artifact, not a real change.\n\nRecord: Report correction, false-alarm note, date",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Correct the report and note the false alarm"
        },
        {
          "detail": "An anomaly with no clear cause after a first pass goes to the practice owner before any staff-facing conversation, vendor call, or spending decision is made.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner review before escalating an unexplained anomaly.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner review before escalating an unexplained anomaly"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "KPI anomaly investigation (sudden drop or spike) — A metric moves outside its expected band.",
      "title": "KPI anomaly investigation (sudden drop or spike)",
      "trigger": "A metric moves outside its expected band",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard KPI set compared against published benchmark ranges (production, collection %, overhead %, hygiene share) — no vendor benchmark tool reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard KPI set compared against published benchmark ranges (production, collection %, overhead %, hygiene share) — no vendor benchmark tool reproduced"
          },
          "source": ": standard KPI set compared against published benchmark ranges (production, collection %, overhead %, hygiene share) — no vendor benchmark tool reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 60,
      "frequency": "quarterly",
      "id": "own-007",
      "kind": "operational",
      "materials": [
        "quarterly rollup of weekly scorecards",
        "published dental practice overhead/hygiene benchmark ranges",
        "prior-quarter goals document"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Aggregate the thirteen weekly scorecards into quarterly totals and averages for each KPI.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Roll up the quarter's weekly scorecards"
        },
        {
          "detail": "Line up this quarter's numbers against last quarter and against the practice's published benchmark ranges for overhead, hygiene share, and collection percentage.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Compare to the prior quarter and to published benchmark ranges"
        },
        {
          "detail": "For each goal set last quarter, mark it met, partially met, or missed, with a one-line reason.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review goal attainment for each prior goal"
        },
        {
          "detail": "Are goals being met overall?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "on-track",
              "label": "Goals broadly on track"
            },
            {
              "goto": "s8",
              "id": "off-track",
              "label": "Meaningfully off track"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Are goals being met overall?"
        },
        {
          "detail": "Set new goals as a modest step up from the current run rate for each KPI, rather than an arbitrary round number.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set next quarter's goals as incremental targets"
        },
        {
          "detail": "Record the quarter's results, goal-attainment notes, and the new goals for next quarter.\n\nRecord: Quarterly results, new goals, date",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Document the quarter's review and new goals"
        },
        {
          "detail": "Quarterly review complete",
          "id": "s7",
          "kind": "step",
          "title": "Quarterly review complete"
        },
        {
          "detail": "Before simply re-setting the same goal, identify what changed (staffing, marketing, case mix) and adjust the plan, not just the number.\n\nWhy: Repeating an unmet goal without changing the underlying plan just produces the same miss next quarter.",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Reassess the plan behind the missed goals before resetting targets",
          "why": "Repeating an unmet goal without changing the underlying plan just produces the same miss next quarter."
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Quarterly goal review, target reset and benchmark comparison (overhead, hygiene share, collection %) — The quarter closes and the scorecard is compared to the prior quarter and to published benchmarks.",
      "title": "Quarterly goal review, target reset and benchmark comparison (overhead, hygiene share, collection %)",
      "trigger": "The quarter closes and the scorecard is compared to the prior quarter and to published benchmarks",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: annual usual-and-customary fee schedule review against cost trend and regional percentile benchmark data — no vendor fee-analysis tool reproduced",
          "source": "Generic functional equivalent: annual usual-and-customary fee schedule review against cost trend and regional percentile benchmark data — no vendor fee-analysis tool reproduced"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 90,
      "frequency": "annual",
      "id": "own-008",
      "kind": "operational",
      "materials": [
        "current fee schedule",
        "lab and supply cost trend",
        "PPO fee schedules by plan",
        "regional fee benchmark reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Gather the current published fee for every active CDT code alongside the past year's lab cost and supply cost trend by category.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the current fee schedule and cost trend"
        },
        {
          "detail": "Check where the practice's fees sit against a regional percentile benchmark for the most common procedure codes, to see which codes have drifted low relative to the market.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Compare current fees to regional benchmark data"
        },
        {
          "detail": "List codes where cost has risen meaningfully, where the fee sits well below benchmark, or where PPO write-offs are unusually high, as candidates for a fee increase.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag codes for adjustment"
        },
        {
          "detail": "Estimate the effect of the proposed new fees on total production, PPO write-off percentage, and patient out-of-pocket cost for the most common treatment plans.",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Model the impact of proposed increases"
        },
        {
          "detail": "Does the increase stay within the practice's tolerance for patient impact?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "within",
              "label": "Impact acceptable, proceed"
            },
            {
              "goto": "s10",
              "id": "too-high",
              "label": "Increase too aggressive, needs trimming"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does the increase stay within the practice's tolerance for patient impact?"
        },
        {
          "detail": "The practice owner reviews and approves the final fee list before it is loaded into the practice management system, communicated to PPO plans as required, or shown to patients — never published on staff authority alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before publishing the new fee schedule.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before publishing the new fee schedule"
        },
        {
          "detail": "Update the practice management system with the new fees, set the effective date, and hand the updated schedule to the insurance coordinator to check against PPO participation agreements.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Load the new fee schedule and notify insurance coordination"
        },
        {
          "detail": "File the prior and new fee schedules, the effective date, and the owner's sign-off for the annual record.\n\nRecord: Old/new fee schedule, effective date, owner sign-off",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the fee schedule update"
        },
        {
          "detail": "Annual fee schedule review complete",
          "id": "s9",
          "kind": "step",
          "title": "Annual fee schedule review complete"
        },
        {
          "detail": "Reduce the size or scope of the increase on the highest-impact codes and re-model the patient-impact estimate before returning to the sign-off decision.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Trim the proposed increases"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Annual fee schedule review and update — The annual fee review date arrives, or lab and supply costs have moved more than the practice threshold.",
      "title": "Annual fee schedule review and update",
      "trigger": "The annual fee review date arrives, or lab and supply costs have moved more than the practice threshold",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source as originally recorded already states it is 'generic accounting practice' with no URL; no published control framework (e.g., a specific COSO citation, state dental-board financial-control rule, or CPA-society standard) was located that specifically mandates own-009 (annual budget/capital plan), own-010 (segregation of duties for cash/posting/adjustments/refunds), or own-017 (practice valuation/exit-readiness) for a dental practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "Internal-control principles (segregation of duties, audit-trail review) — generic accounting practice",
              "url": null
            }
          },
          "source": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Annual budget build and capital-plan worksheet structure: (standard small-business budgeting practice) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Annual budget build and capital-plan worksheet structure: generic functional equivalent (standard small-business budgeting practice)"
          },
          "source": "Annual budget build and capital-plan worksheet structure: (standard small-business budgeting practice) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 240,
      "frequency": "annual",
      "id": "own-009",
      "kind": "operational",
      "materials": [
        "prior 12 months' P&L",
        "current overhead percentage by category",
        "production goal worksheet",
        "capital equipment wish list with quotes",
        "cash reserve target"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Office manager exports the trailing 12 months of profit and loss, production, and collection figures from the accounting and practice-management systems.\n\nWhy: A forward budget starts from a documented trailing baseline, not memory or estimate.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the prior 12 months' P&L and production/collection history",
          "why": "A forward budget starts from a documented trailing baseline, not memory or estimate."
        },
        {
          "detail": "Group expenses into standard categories (staff compensation, lab, supplies, rent/occupancy, marketing, insurance, admin) and compute each as a percent of trailing collections.\n\nWhy: Overhead-as-a-percent lets the owner compare against benchmark bands regardless of practice size.\n\nRecord: overhead by category as percent of collections, prior 12 months",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Categorize overhead by line item and compute each as a percent of collections",
          "why": "Overhead-as-a-percent lets the owner compare against benchmark bands regardless of practice size."
        },
        {
          "detail": "Owner and office manager flag any category running materially above its expected band (e.g. staff compensation running well above the practice's own historical norm) for closer review.\n\nWhy: A category drifting outside its own historical band is the signal worth a decision, not the raw dollar figure alone.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Compare each overhead category to the practice's benchmark band",
          "why": "A category drifting outside its own historical band is the signal worth a decision, not the raw dollar figure alone."
        },
        {
          "detail": "Owner sets a target production and collection figure for the coming year, informed by trailing trend, planned schedule changes, and any new provider or hygiene capacity.\n\nWhy: The rest of the budget (staffing, marketing spend, capital affordability) is built against this target.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set next year's production and collection goal",
          "why": "The rest of the budget (staffing, marketing spend, capital affordability) is built against this target."
        },
        {
          "detail": "Office manager compiles requested capital purchases (equipment replacement, technology upgrades, facility improvements) with vendor quotes and expected useful life for each.\n\nWhy: Capital decisions need a real dollar figure and a useful-life estimate to compare against affordability, not a wish alone.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the capital equipment wish list with quotes",
          "why": "Capital decisions need a real dollar figure and a useful-life estimate to compare against affordability, not a wish alone."
        },
        {
          "detail": "Owner decides whether each capital item is funded from cash reserve, financed, or deferred, based on whether funding it keeps the cash reserve at or above the practice's target months-on-hand.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "fund-from-cash",
              "label": "Fund from cash reserve without dropping below target months-on-hand"
            },
            {
              "goto": "s7",
              "id": "finance-or-defer",
              "label": "Finance the item or defer to next year"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Check capital plan affordability against cash reserve target and financing options"
        },
        {
          "detail": "Office manager assembles the final document: monthly production/collection targets, overhead category targets, approved capital spend and its funding source, and cash reserve target.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft the written annual budget"
        },
        {
          "detail": "Practice owner reviews and signs off on the final budget and capital plan before it becomes the operating plan for the year.\n\nWhy: Committing to capital spend and hiring plans is a money decision that belongs to the owner, not staff.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before the budget takes effect.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before the budget takes effect",
          "why": "Committing to capital spend and hiring plans is a money decision that belongs to the owner, not staff."
        },
        {
          "detail": "Approved budget and capital plan are shared with the bookkeeper or accountant for monthly variance tracking and with the office manager for operational planning.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Distribute the approved budget to the bookkeeper/accountant and office manager"
        },
        {
          "detail": "Store the signed budget, capital plan, and supporting quotes in the practice's governance records for the year.\n\nRecord: approved annual budget, capital plan, funding source per item, owner sign-off date",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "File the approved annual budget and capital plan"
        },
        {
          "detail": "Annual budget and capital plan cycle closed",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Annual budget and capital plan cycle closed"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Annual budget build and capital plan — Annually before the fiscal year.",
      "title": "Annual budget build and capital plan",
      "trigger": "Annually before the fiscal year",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source as originally recorded already states it is 'generic accounting practice' with no URL; no published control framework (e.g., a specific COSO citation, state dental-board financial-control rule, or CPA-society standard) was located that specifically mandates own-009 (annual budget/capital plan), own-010 (segregation of duties for cash/posting/adjustments/refunds), or own-017 (practice valuation/exit-readiness) for a dental practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "Internal-control principles (segregation of duties, audit-trail review) — generic accounting practice",
              "url": null
            }
          },
          "source": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "own-010",
      "kind": "operational",
      "materials": [
        "practice-management system role/permission list",
        "list of money-handling tasks (cash receipt, posting, adjustment, refund, deposit)",
        "segregation-of-duties matrix template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager lists each distinct money task: taking cash/card payment, posting payments to accounts, entering adjustments or write-offs, issuing refunds, making the bank deposit, reconciling the deposit to the day sheet.\n\nWhy: Segregation of duties only works if every discrete task is named, not just the general area of 'billing.'",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "List every money-handling task in the practice",
          "why": "Segregation of duties only works if every discrete task is named, not just the general area of 'billing.'"
        },
        {
          "detail": "For each task on the list, record who has system permission to perform it today, using the practice-management system's role/permission list.\n\nWhy: The gap can't be closed until the current state is documented.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Map which staff member currently performs each task",
          "why": "The gap can't be closed until the current state is documented."
        },
        {
          "detail": "Owner and office manager check whether any one role or person can receive payment, post it, adjust it, and issue a refund unilaterally, with no independent check.\n\nWhy: That combination is the classic embezzlement pattern: one person controls the entire cash cycle end to end. 'Advised' here marks the expected first-pass finding for a practice running this check for the first time (assume overlap exists until the matrix proves otherwise) — it is not a recommendation that overlap is the preferred outcome.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "overlap-found",
              "label": "Overlap found — one person can complete the full cash cycle alone"
            },
            {
              "goto": "s5",
              "id": "no-overlap",
              "label": "No overlap — duties are already split"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Identify any single staff member who can both handle cash and post/adjust/refund without a second person involved",
          "why": "That combination is the classic embezzlement pattern: one person controls the entire cash cycle end to end. 'Advised' here marks the expected first-pass finding for a practice running this check for the first time (assume overlap exists until the matrix proves otherwise) — it is not a recommendation that overlap is the preferred outcome."
        },
        {
          "detail": "Practice owner or office manager reviews and approves any change to who can perform which money task before permissions are altered in the system.\n\nWhy: Permission changes affect every staff member's daily workflow and need a documented decision-maker.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner or office-manager sign-off required before restructuring money-handling permissions.",
            "role": "practice-owner or office-manager",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner or office-manager sign-off required before restructuring money-handling permissions",
          "why": "Permission changes affect every staff member's daily workflow and need a documented decision-maker."
        },
        {
          "detail": "Assign at minimum: the person who takes payment is not the sole person who can post an adjustment or refund without a second approver; the person who makes the deposit is not the same person who reconciles it.\n\nWhy: Splitting receipt, posting/adjustment, and deposit reconciliation across at least two people is the standard control against unrecorded skimming or fictitious adjustments.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Design the segregation-of-duties matrix",
          "why": "Splitting receipt, posting/adjustment, and deposit reconciliation across at least two people is the standard control against unrecorded skimming or fictitious adjustments."
        },
        {
          "detail": "Configure the practice-management system (or a manual sign-off log where the system cannot enforce it) so that any adjustment, write-off or refund requires sign-off from a second staff member or the owner.\n\nWhy: A single-person adjustment with no second look is the specific control gap the monthly audit-trail review (own-004) exists to catch after the fact — this step prevents it up front.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Require a second approver for every adjustment, write-off and refund above a set threshold",
          "why": "A single-person adjustment with no second look is the specific control gap the monthly audit-trail review (own-004) exists to catch after the fact — this step prevents it up front."
        },
        {
          "detail": "Office manager (or IT vendor, if system access requires it) updates each staff member's system role so their actual permissions match the approved segregation-of-duties matrix.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Update system permissions to match the matrix"
        },
        {
          "detail": "Explain to staff why duties are split — this protects them as much as the practice, since no single employee can be wrongly suspected of a discrepancy they didn't cause alone.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief affected staff on the new task split"
        },
        {
          "detail": "Store the approved matrix, the date it took effect, and the date it is next due for review (at minimum, at every staffing change in a money-handling role).\n\nRecord: segregation-of-duties matrix, effective date, staff assignments, next review date",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "File the segregation-of-duties matrix and next review date"
        },
        {
          "detail": "Segregation-of-duties setup complete",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Segregation-of-duties setup complete"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Segregation of duties for cash, posting, adjustments and refunds — Practice setup or any staffing change in a money-handling role.",
      "title": "Segregation of duties for cash, posting, adjustments and refunds",
      "trigger": "Practice setup or any staffing change in a money-handling role",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "PPO fee-schedule negotiation and participation review process: generic functional equivalent (no payer-specific contract terms reproduced)",
          "source": "PPO fee-schedule negotiation and participation review process: generic functional equivalent (no payer-specific contract terms reproduced)"
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 180,
      "frequency": "annual",
      "id": "own-011",
      "kind": "operational",
      "materials": [
        "current PPO participation list and fee schedules",
        "production-by-plan report",
        "write-off percentage by plan",
        "plan renewal/notice-of-change letters"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "insurance-coordinator",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Insurance coordinator exports total production, collected amount, and write-off (adjustment to the contracted fee) for each participating PPO plan over the trailing 12 months.\n\nWhy: A plan's value to the practice is what it actually pays out after write-offs, not its listed fee schedule.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Pull production, collection and write-off figures by plan for the trailing year",
          "why": "A plan's value to the practice is what it actually pays out after write-offs, not its listed fee schedule."
        },
        {
          "detail": "For each plan, compute write-off as a percent of billed charges and the resulting effective collection rate compared to the practice's standard fee.\n\nRecord: write-off percent and effective collection rate per plan",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Compute write-off percent and effective collection rate by plan"
        },
        {
          "detail": "Owner reviews the per-plan figures and flags any plan whose write-off percent is notably higher than the others, or whose renewal letter proposes a fee-schedule reduction.\n\nWhy: 'Advised' here marks the expected first-pass finding in an annual review meant to surface outliers — it is not a recommendation that a flagged plan is the preferred outcome.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "flagged",
              "label": "One or more plans flagged for renegotiation or drop consideration"
            },
            {
              "goto": "s10",
              "id": "no-flags",
              "label": "All plans within acceptable range — no action needed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Flag plans with a write-off percent materially worse than the practice average",
          "why": "'Advised' here marks the expected first-pass finding in an annual review meant to surface outliers — it is not a recommendation that a flagged plan is the preferred outcome."
        },
        {
          "detail": "Owner decides for each flagged plan whether to attempt fee-schedule renegotiation, accept the terms as-is, or drop participation.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "renegotiate",
              "label": "Attempt renegotiation before accepting new terms"
            },
            {
              "goto": "s7",
              "id": "accept-or-drop",
              "label": "Accept terms as-is or drop the plan"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to renegotiate, accept, or drop each flagged plan"
        },
        {
          "detail": "Owner or insurance coordinator contacts the payer's provider-relations line to request a fee-schedule review, citing the practice's write-off data and local market comparison where available.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Contact the payer to negotiate the fee schedule"
        },
        {
          "detail": "Note whether the payer improved terms, held firm, or the deadline to respond to the renewal notice is approaching.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "improved",
              "label": "Terms improved — continue participation"
            },
            {
              "goto": "s7",
              "id": "unchanged",
              "label": "Terms unchanged — owner makes final accept/drop call"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Record the negotiation outcome"
        },
        {
          "detail": "If a plan is dropped or terms change, insurance coordinator briefs front desk (for patient-facing eligibility conversations) and billing (for claims processing changes), with an effective date.\n\nWhy: A dropped plan that front desk doesn't know about leads to a patient being told they're covered when they aren't.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Notify front desk and billing of any participation change",
          "why": "A dropped plan that front desk doesn't know about leads to a patient being told they're covered when they aren't."
        },
        {
          "detail": "Record the per-plan write-off data, decisions made, and next review date in the practice's governance records.\n\nRecord: per-plan write-off percent, participation decisions, effective dates, next review date",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "File the annual PPO participation review outcome"
        },
        {
          "detail": "Annual PPO participation review closed",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Annual PPO participation review closed"
        },
        {
          "detail": "Insurance coordinator confirms continued participation with each plan whose terms did not change, updating the participation list's next-review date.",
          "id": "s10",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm continued participation on unchanged terms"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Annual PPO participation and fee-schedule negotiation review — The annual participation review date arrives, or a plan renews its contract.",
      "title": "Annual PPO participation and fee-schedule negotiation review",
      "trigger": "The annual participation review date arrives, or a plan renews its contract",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced"
          },
          "source": ": standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "CA B&P §16600 (non-compete unenforceability) — relevant where the associate contract includes restrictive covenants",
          "source": "CA B&P §16600 (non-compete unenforceability) — relevant where the associate contract includes restrictive covenants",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=16600",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "Associate compensation review process — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Associate compensation review process: generic functional equivalent"
          },
          "source": "Associate compensation review process — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 120,
      "frequency": "annual",
      "id": "own-012",
      "kind": "operational",
      "materials": [
        "current associate contract",
        "associate's trailing-12-month production and collection figures",
        "compensation formula worksheet (percent of production/collections, guarantees, bonus structure)",
        "market compensation benchmark reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Office manager exports the associate dentist's production, collections, and any bonus-relevant metrics (case acceptance, hygiene referral rate) for the prior 12 months.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the associate's trailing 12-month production and collection figures"
        },
        {
          "detail": "Owner reviews the existing contract's compensation structure (base guarantee, percent of production or collections, bonus tiers), term length, and any restrictive covenants.\n\nWhy: The renewal decision has to start from what the contract actually says today, not what either party remembers.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the current contract's compensation formula and terms",
          "why": "The renewal decision has to start from what the contract actually says today, not what either party remembers."
        },
        {
          "detail": "The practice owner (a licensed dentist) or a designated licensed reviewer confirms proposed changes to clinical scope, supervision terms, or productivity expectations are clinically and professionally appropriate before terms are drafted for signature.\n\nWhy: Associate contracts often touch clinical scope and supervision arrangements, which are licensed-professional decisions, not purely business ones.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before any compensation or scope-of-practice terms are finalized.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Licensed sign-off before any compensation or scope-of-practice terms are finalized",
          "why": "Associate contracts often touch clinical scope and supervision arrangements, which are licensed-professional decisions, not purely business ones."
        },
        {
          "detail": "Owner compares the associate's current compensation formula and effective take-home against a general market benchmark reference for the region and specialty, where one is available.\n\nWhy: Retention risk rises when compensation drifts noticeably below what the associate could reasonably expect elsewhere.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Compare current compensation to a market benchmark reference",
          "why": "Retention risk rises when compensation drifts noticeably below what the associate could reasonably expect elsewhere."
        },
        {
          "detail": "Owner decides the practice's opening position ahead of the conversation with the associate.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "renew-as-is",
              "label": "Renew on current terms"
            },
            {
              "goto": "s6",
              "id": "propose-amendment",
              "label": "Propose amended compensation or terms"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to renew as-is, amend terms, or open renegotiation"
        },
        {
          "detail": "Owner meets with the associate to discuss production trends, proposed terms, and gathers the associate's own feedback before finalizing.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Hold the renewal conversation with the associate"
        },
        {
          "detail": "Owner (with legal review where terms materially change) drafts the renewal or amendment for signature.\n\nWhy: A materially changed contract benefits from legal review before signature, same as any employment agreement.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Finalize and draft the renewed or amended contract",
          "why": "A materially changed contract benefits from legal review before signature, same as any employment agreement."
        },
        {
          "detail": "The practice owner (a licensed dentist) confirms the final drafted compensation formula and any clinical scope or supervision terms are accurate and professionally appropriate before either party signs — this applies whether the contract renews as-is or carries amended terms.\n\nWhy: The earlier licensed-review-gate confirmed the pre-negotiation baseline; a changed compensation or scope term coming out of the associate conversation needs its own explicit sign-off right before it becomes binding, not just a pre-negotiation check.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the final compensation and scope terms before execution.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Licensed sign-off on the final compensation and scope terms before execution",
          "why": "The earlier licensed-review-gate confirmed the pre-negotiation baseline; a changed compensation or scope term coming out of the associate conversation needs its own explicit sign-off right before it becomes binding, not just a pre-negotiation check."
        },
        {
          "detail": "Both parties sign; office manager files the executed contract with prior versions and updates the compensation formula in the payroll/production system.\n\nRecord: executed contract, compensation formula, effective date, next anniversary date",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Execute and file the renewed contract"
        },
        {
          "detail": "Associate contract and compensation review closed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Associate contract and compensation review closed"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Associate dentist contract and compensation review — Contract anniversary.",
      "title": "Associate dentist contract and compensation review",
      "trigger": "Contract anniversary",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Peer case-review discussion format: (standard clinical mentorship practice) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Peer case-review discussion format: generic functional equivalent (standard clinical mentorship practice)"
          },
          "source": "Peer case-review discussion format: (standard clinical mentorship practice) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 30,
      "frequency": "weekly",
      "id": "own-013",
      "kind": "operational",
      "materials": [
        "list of the associate's complex or borderline cases from the week",
        "prior week's follow-up items"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ahead of the meeting, the associate lists cases from the week that were diagnostically complex, had an unusual treatment plan, involved a complication, or had a case-acceptance challenge.\n\nWhy: A weekly review works best focused on the cases that actually raised a question, not a full recap of every patient seen.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Associate compiles the week's complex or borderline cases",
          "why": "A weekly review works best focused on the cases that actually raised a question, not a full recap of every patient seen."
        },
        {
          "detail": "Owner and associate check whether action items from last week's review (a referral made, a treatment plan revisited, a technique discussed) were completed.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review outstanding follow-up items from the prior week"
        },
        {
          "detail": "For each case: associate presents the diagnostic finding and proposed or completed treatment plan; owner offers a second clinical perspective, alternative approaches considered, and any concerns.\n\nWhy: This is the routine mechanism by which a newer associate gets ongoing clinical calibration against the practice's standard of care.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Walk through each listed case",
          "why": "This is the routine mechanism by which a newer associate gets ongoing clinical calibration against the practice's standard of care."
        },
        {
          "detail": "Where the owner's review surfaces a recommended change to a treatment plan already presented to or accepted by a patient, that change is confirmed and documented by a licensed dentist (the owner or the treating associate) before it is communicated to the patient.\n\nWhy: A treatment-plan change is a clinical decision that needs a licensed practitioner's explicit sign-off, not an informal mentoring note alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on any case where the owner recommends a treatment-plan change.",
            "role": "practice-owner or treating dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Licensed sign-off on any case where the owner recommends a treatment-plan change",
          "why": "A treatment-plan change is a clinical decision that needs a licensed practitioner's explicit sign-off, not an informal mentoring note alone."
        },
        {
          "detail": "Record any action items arising from the discussion (a plan revision to communicate, a technique to revisit, a referral to make) for next week's check.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Note any new follow-up items"
        },
        {
          "detail": "Note the cases discussed (by identifier, not full clinical detail) and open follow-up items in the practice's mentorship/case-review log.\n\nRecord: cases discussed (identifiers only), follow-up items and owners, date",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the session summary"
        },
        {
          "detail": "Weekly case review closed",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Weekly case review closed"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Associate–owner weekly case review — Weekly fixed slot.",
      "title": "Associate–owner weekly case review",
      "trigger": "Weekly fixed slot",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Contract-date tracking calendar practice: (standard small-business contract management) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Contract-date tracking calendar practice: generic functional equivalent (standard small-business contract management)"
          },
          "source": "Contract-date tracking calendar practice: (standard small-business contract management) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 45,
      "frequency": "quarterly",
      "id": "own-014",
      "kind": "operational",
      "materials": [
        "master contract calendar (lease, equipment financing, service contracts, malpractice, licenses)",
        "current lease agreement",
        "current equipment financing schedules"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Office manager opens the practice's master calendar of key contracts: facility lease, equipment financing/leases, major service and maintenance contracts, malpractice policy renewal, and business licenses.\n\nWhy: A single tracked list is the only reliable way to catch a renewal deadline months in advance rather than the week it lapses.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the master contract calendar",
          "why": "A single tracked list is the only reliable way to catch a renewal deadline months in advance rather than the week it lapses."
        },
        {
          "detail": "Office manager flags every entry with an option-to-renew window, renewal deadline, or expiration date falling within the next six months.\n\nRecord: flagged contracts with dates and required action window",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag any contract with an option, renewal, or expiration date in the coming two quarters"
        },
        {
          "detail": "Determine whether action is needed this quarter.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "flagged",
              "label": "One or more contracts flagged"
            },
            {
              "goto": "s8",
              "id": "none-flagged",
              "label": "Nothing flagged this quarter"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Any contracts flagged?"
        },
        {
          "detail": "For lease: renew, renegotiate, or plan relocation. For equipment financing: pay off, refinance, or replace equipment. For service contracts: renew, renegotiate, or switch provider. For malpractice/licenses: confirm renewal is in process.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Owner reviews each flagged contract's terms and decides a course of action"
        },
        {
          "detail": "The practice owner personally confirms the specific course of action (exercise the lease option, sign new financing terms, switch a service provider) before the office manager initiates it — these are often irrevocable, legally binding commitments.\n\nWhy: Exercising a lease renewal option or signing new equipment financing binds the practice for years; it stays owner-gated even though the review itself is routine and quarterly.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before exercising a lease option, refinancing, or signing new contract terms.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before exercising a lease option, refinancing, or signing new contract terms",
          "why": "Exercising a lease renewal option or signing new equipment financing binds the practice for years; it stays owner-gated even though the review itself is routine and quarterly."
        },
        {
          "detail": "Office manager initiates the renewal, negotiation, or notice required by the contract's own notice period (many commercial leases require 90-180 days' written notice to exercise an option).\n\nWhy: Missing a lease option-notice window can force the practice into a month-to-month tenancy or loss of the space at renewal.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Take the required action with adequate lead time before the deadline",
          "why": "Missing a lease option-notice window can force the practice into a month-to-month tenancy or loss of the space at renewal."
        },
        {
          "detail": "Office manager confirms written confirmation was received (renewal notice sent and acknowledged, new financing terms signed, license renewal filed).",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the action was completed and documented"
        },
        {
          "detail": "Record which contracts were reviewed, which were flagged, what action was taken, and update the master calendar with new dates.\n\nRecord: quarterly review date, flagged contracts, actions taken, updated dates in master calendar",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the quarterly contract-date review"
        },
        {
          "detail": "Quarterly lease and contract-date review closed",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Quarterly lease and contract-date review closed"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Lease, equipment financing and key contract date tracking — Quarterly review of option and renewal dates.",
      "title": "Lease, equipment financing and key contract date tracking",
      "trigger": "Quarterly review of option and renewal dates",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced"
          },
          "source": ": standard KPI set (production, collection %, new patients, reappointment %, case acceptance, no-show rate, AR over 90) — no analytics vendor or consultancy scorecard reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "source": "Dental Board of California guidance on practice closure, sale and record custody; CA H&S §123145 (record retention)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "statute",
          "label": "Dental Practice Act, B&P Div. 2 Ch. 4, unprofessional conduct grounds (including patient-abandonment concerns during a licensee's absence or incapacity) — exact section pending licensed-review verification; citation generalized rather than pinned to a specific subsection",
          "source": "Dental Practice Act, B&P Div. 2 Ch. 4, unprofessional conduct grounds (including patient-abandonment concerns during a licensee's absence or incapacity) — exact section pending licensed-review verification; citation generalized rather than pinned to a specific subsection"
        },
        {
          "kind": "generic",
          "label": "Owner-incapacity continuity plan structure (covering dentist, signatory succession, records custodian) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Owner-incapacity continuity plan structure (covering dentist, signatory succession, records custodian): generic functional equivalent"
          },
          "source": "Owner-incapacity continuity plan structure (covering dentist, signatory succession, records custodian) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 180,
      "frequency": "annual",
      "id": "own-015",
      "kind": "operational",
      "materials": [
        "designated covering-dentist agreement",
        "signatory authorization list (bank, payroll, controlled-substance ordering)",
        "records-custodian designation",
        "emergency contact list",
        "power-of-attorney or incapacity plan documents where applicable"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Owner identifies another licensed dentist (partner, associate, or an outside colleague with a standing agreement) willing to step in and see urgent patients if the owner becomes suddenly unavailable, and confirms the arrangement is current.\n\nWhy: Patients cannot be left without any prescriber or licensed decision-maker if the owner is incapacitated without notice.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Identify and confirm a designated covering dentist",
          "why": "Patients cannot be left without any prescriber or licensed decision-maker if the owner is incapacitated without notice."
        },
        {
          "detail": "The designated covering dentist (a licensed practitioner) confirms in writing their willingness and current licensure/malpractice coverage to act as covering dentist before the plan is finalized.\n\nWhy: An out-of-date or unconfirmed covering-dentist arrangement is worthless in an actual incapacity event; this has to be a live, confirmed commitment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off confirming the covering dentist arrangement is valid and current.",
            "role": "designated covering dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off confirming the covering dentist arrangement is valid and current",
          "why": "An out-of-date or unconfirmed covering-dentist arrangement is worthless in an actual incapacity event; this has to be a live, confirmed commitment."
        },
        {
          "detail": "List who can act on the practice's bank accounts, payroll, and (where applicable) controlled-substance ordering if the owner is unavailable — this typically requires advance arrangement with the bank and DEA registrant records, not something set up after the fact.\n\nWhy: Payroll and bill payment cannot stop simply because the owner is unreachable; someone else needs pre-authorized signing authority.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Document the signatory succession list",
          "why": "Payroll and bill payment cannot stop simply because the owner is unreachable; someone else needs pre-authorized signing authority."
        },
        {
          "detail": "Name who is responsible for patient record custody, access, and continuity of care coordination if the owner cannot fulfill that role, consistent with state record-retention and custody requirements.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Designate a records custodian"
        },
        {
          "detail": "Compile contacts for the covering dentist, designated signatory, records custodian, malpractice carrier, and the owner's personal emergency contact, in one accessible document.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the emergency contact list"
        },
        {
          "detail": "Office manager ensures at least one other staff member (in addition to the owner) knows where the continuity plan is stored and who to call first in an incapacity event.\n\nWhy: A plan that only the owner knows about fails exactly when it's needed.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief key staff on where the plan is kept and what to do",
          "why": "A plan that only the owner knows about fails exactly when it's needed."
        },
        {
          "detail": "Each year (or before any planned absence over two weeks), reconfirm the covering dentist, signatories, and records custodian are still willing and available.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm all designees remain current and willing"
        },
        {
          "detail": "Store the signed continuity plan, all designee confirmations, and the emergency contact list; set next review for one year out.\n\nRecord: continuity plan, designee confirmations, emergency contact list, next review date",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "File the continuity plan and confirm the next review date"
        },
        {
          "detail": "Owner absence/incapacity continuity plan complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Owner absence/incapacity continuity plan complete"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Owner absence or incapacity continuity plan (covering dentist, signatory, records custodian) — Annually, and before any owner absence longer than two weeks.",
      "title": "Owner absence or incapacity continuity plan (covering dentist, signatory, records custodian)",
      "trigger": "Annually, and before any owner absence longer than two weeks",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Strategic-option evaluation framework (capacity, financial, risk review before a hire/expand/sell/partner decision) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Strategic-option evaluation framework (capacity, financial, risk review before a hire/expand/sell/partner decision): generic functional equivalent"
          },
          "source": "Strategic-option evaluation framework (capacity, financial, risk review before a hire/expand/sell/partner decision) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "own-016",
      "kind": "operational",
      "materials": [
        "current-year scorecard and budget vs actual",
        "capacity analysis (schedule utilization, chair/operatory availability)",
        "opportunity summary (hire, expand, sell, partner, as applicable)",
        "advisor list (accountant, attorney, broker as applicable)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Owner reviews production/collection trend, budget performance, and schedule/operatory utilization to establish where the practice actually stands before considering any growth move.\n\nWhy: A growth decision made without a current capacity and financial baseline risks over-expanding or under-resourcing.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review the current-year scorecard, budget-vs-actual, and capacity picture",
          "why": "A growth decision made without a current capacity and financial baseline risks over-expanding or under-resourcing."
        },
        {
          "detail": "Owner categorizes the material opportunity or annual planning question: adding a provider or hygienist, expanding operatories or a second location, selling or partnering with an outside entity, or none of these (steady-state year).",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "hire-expand",
              "label": "Hire or expand capacity"
            },
            {
              "goto": "s8",
              "id": "sell-partner",
              "label": "Sell or bring in a partner/outside entity"
            },
            {
              "goto": "s6",
              "id": "steady-state",
              "label": "Steady-state year — no material change"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Identify the type of strategic decision at hand"
        },
        {
          "detail": "Owner analyzes schedule utilization, whether existing operatories can absorb the added volume, and the break-even production needed to justify the new hire or expansion cost.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Run a capacity analysis for the hire or expansion option"
        },
        {
          "detail": "Owner weighs the capacity analysis against the annual budget (own-009) and current cash position.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "proceed",
              "label": "Proceed with hire/expansion"
            },
            {
              "goto": "s6",
              "id": "defer",
              "label": "Defer to a future year"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to proceed with the hire or expansion"
        },
        {
          "detail": "The practice owner personally confirms the hire or expansion commitment (offer extended, lease signed, equipment ordered) before it proceeds — this is a money and staffing commitment that stays owner-gated even on the capacity-supported path.\n\nWhy: Every branch of this decision — sell/partner or hire/expand — reaches a consequential commitment; hire/expand should not reach that commitment with no checkpoint just because it looked capacity-supported on paper.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before committing to the hire or expansion.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before committing to the hire or expansion",
          "why": "Every branch of this decision — sell/partner or hire/expand — reaches a consequential commitment; hire/expand should not reach that commitment with no checkpoint just because it looked capacity-supported on paper."
        },
        {
          "detail": "Record the opportunity considered, the decision made, and the reasoning, in the practice's governance records for future reference.\n\nRecord: opportunity type, decision, rationale, date, advisors consulted if any",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the strategic decision and rationale"
        },
        {
          "detail": "Strategic planning and growth decision cycle closed",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Strategic planning and growth decision cycle closed"
        },
        {
          "detail": "For any sale, partnership, or outside-entity discussion, the owner engages an accountant, attorney, and/or business broker as applicable before entering substantive negotiation.\n\nWhy: A sale or partnership decision has legal, tax and valuation dimensions no single owner should navigate without professional advice — this is a money and legal decision, not an operational one, so it stays owner-gated.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner engages outside advisors before proceeding with a sale or partnership discussion.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner engages outside advisors before proceeding with a sale or partnership discussion",
          "why": "A sale or partnership decision has legal, tax and valuation dimensions no single owner should navigate without professional advice — this is a money and legal decision, not an operational one, so it stays owner-gated."
        },
        {
          "detail": "Owner reviews any proposed terms with the engaged accountant/attorney/broker before making a decision.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Evaluate proposed terms with advisors"
        },
        {
          "detail": "Owner makes the final decision on whether to move forward, informed by advisor review.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "proceed-sale",
              "label": "Proceed toward a transaction (see business-transitions-and-continuity class for execution)"
            },
            {
              "goto": "s6",
              "id": "decline",
              "label": "Decline the opportunity"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to proceed with the sale or partnership"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Strategic planning and growth decision (hire, expand, sell, partner) — Annually or when a material opportunity arises.",
      "title": "Strategic planning and growth decision (hire, expand, sell, partner)",
      "trigger": "Annually or when a material opportunity arises",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard practice valuation drivers (EBITDA multiple, collections trend, payer mix, lease term, associate dependency) — no consultancy or broker methodology reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard practice valuation drivers (EBITDA multiple, collections trend, payer mix, lease term, associate dependency) — no consultancy or broker methodology reproduced"
          },
          "source": ": standard practice valuation drivers (EBITDA multiple, collections trend, payer mix, lease term, associate dependency) — no consultancy or broker methodology reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "The source as originally recorded already states it is 'generic accounting practice' with no URL; no published control framework (e.g., a specific COSO citation, state dental-board financial-control rule, or CPA-society standard) was located that specifically mandates own-009 (annual budget/capital plan), own-010 (segregation of duties for cash/posting/adjustments/refunds), or own-017 (practice valuation/exit-readiness) for a dental practice.",
            "ticket": "PROT-017",
            "was": {
              "source": "Internal-control principles (segregation of duties, audit-trail review) — generic accounting practice",
              "url": null
            }
          },
          "source": "No specific regulation or published standard found. Segregation-of-duties and audit-trail-review controls are general business/accounting practice, not mandated by a single citable authority for a dental practice — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "own-017",
      "kind": "operational",
      "materials": [
        "trailing-3-year P&L and tax returns",
        "current fee schedule",
        "provider productivity report",
        "lease and equipment lease terms",
        "payer mix report",
        "de-identified valuation checklist template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Owner decides whether this is the routine every-two-to-three-year check-in or a check triggered by an active decision (considering a sale, partner buy-in, or DSO conversation).\n\nWhy: An active-decision valuation moves faster and pulls in outside advisors sooner than a routine check-in.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "routine",
              "label": "Routine periodic check-in, no active decision pending"
            },
            {
              "goto": "s2",
              "id": "active",
              "label": "Active decision pending (sale, buy-in, DSO offer)"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Confirm why a valuation check is happening now",
          "why": "An active-decision valuation moves faster and pulls in outside advisors sooner than a routine check-in."
        },
        {
          "detail": "Office manager compiles trailing-3-year P&L, tax returns, provider productivity reports, and the current fee schedule into one packet for the owner's review.\n\nWhy: A single-year snapshot hides a trend a buyer or advisor will immediately ask about.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather trailing-3-year financial and production records",
          "why": "A single-year snapshot hides a trend a buyer or advisor will immediately ask about."
        },
        {
          "detail": "Office manager pulls the percentage of production from each payer over the trailing 12 months and flags any single payer above roughly a third of production.\n\nWhy: Revenue concentrated in one or two payers is a recognized valuation risk factor — a payer contract change or exit can swing revenue sharply.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Review payer mix and revenue concentration",
          "why": "Revenue concentrated in one or two payers is a recognized valuation risk factor — a payer contract change or exit can swing revenue sharply."
        },
        {
          "detail": "Owner reviews what share of total production depends on the owner personally treating patients versus associates or hygienists, since a practice that cannot function without the owner chairside is harder to transition.\n\nWhy: Buyers and successors discount heavily for practices where patients are loyal to the owner specifically rather than the practice brand.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Assess owner-versus-associate production dependency",
          "why": "Buyers and successors discount heavily for practices where patients are loyal to the owner specifically rather than the practice brand."
        },
        {
          "detail": "Office manager pulls years remaining on the facility lease, any assignment/transfer clauses, and the age and condition of major equipment (chairs, imaging, sterilization).\n\nWhy: A short remaining lease term or non-transferable lease can materially affect what a buyer or successor is willing to pay.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Review lease terms and major equipment condition",
          "why": "A short remaining lease term or non-transferable lease can materially affect what a buyer or successor is willing to pay."
        },
        {
          "detail": "Owner (with a bookkeeper or accountant if engaged) applies a standard EBITDA-multiple framework to trailing collections and adjusted earnings to produce a rough, non-binding range — noted explicitly as an internal estimate, not an appraisal.\n\nWhy: An internal rough range lets the owner decide whether it is worth paying for a formal, licensed valuation before committing time to a sale process.\n\nRecord: rough valuation range and the assumptions behind it",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Build a rough valuation range using standard drivers",
          "why": "An internal rough range lets the owner decide whether it is worth paying for a formal, licensed valuation before committing time to a sale process."
        },
        {
          "detail": "Owner compares the rough range to what would be needed for a target outcome and flags gaps: payer concentration, associate dependency, thin documentation, deferred maintenance, or unclear provider agreements.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-gaps",
              "label": "No material gaps found"
            },
            {
              "goto": "s12",
              "id": "gaps-found",
              "label": "Material gaps found (concentration, dependency, documentation)"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Identify readiness gaps against the rough range"
        },
        {
          "detail": "The practice owner personally reviews and approves the packet before any financial detail, valuation range, or readiness assessment is shared with a broker, accountant, attorney, or prospective buyer.\n\nWhy: Practice financials and valuation estimates are sensitive; nothing leaves the practice without an explicit owner decision to share it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before engaging outside advisors or sharing financials externally.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before engaging outside advisors or sharing financials externally",
          "why": "Practice financials and valuation estimates are sensitive; nothing leaves the practice without an explicit owner decision to share it."
        },
        {
          "detail": "Owner decides whether the active-decision path (own-017 confirm-horizon = active) or a material readiness gap warrants engaging a licensed valuation professional, broker, or attorney now, or whether the file is simply archived until the next periodic check.",
          "forks": [
            {
              "goto": "s13",
              "id": "engage",
              "label": "Engage a licensed valuation professional / broker / attorney"
            },
            {
              "advised": true,
              "goto": "s10",
              "id": "archive",
              "label": "Archive for the next periodic check-in"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide whether to engage outside advisors now"
        },
        {
          "detail": "Record the date of this check-in, the rough valuation range, gaps identified, and whether outside advisors were engaged, in the owner governance log.\n\nRecord: check-in date, rough range, gaps identified, advisor engagement status",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the valuation check-in cycle"
        },
        {
          "detail": "Valuation and exit-readiness cycle closed",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Valuation and exit-readiness cycle closed"
        },
        {
          "detail": "Owner and office manager list each gap with an owner, a target date, and what evidence would show it closed (e.g. payer mix diversified, associate agreement formalized, deferred maintenance completed).\n\nWhy: Gaps found now and fixed over a year or two materially change the eventual outcome; gaps found during an active sale process are usually just a lower offer.\n\nRecord: remediation plan with owners and target dates",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Draft a remediation plan for the gaps found",
          "why": "Gaps found now and fixed over a year or two materially change the eventual outcome; gaps found during an active sale process are usually just a lower offer."
        },
        {
          "detail": "Office manager transmits the approved financial and readiness packet to the engaged broker, accountant, or attorney, and logs who received it and when.\n\nRecord: advisor engaged, packet transmission date",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the packet to the engaged outside advisor"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Practice valuation and exit-readiness check — Every two to three years, or when the owner begins seriously considering a sale, partner buy-in, or DSO affiliation within the next 24 months.",
      "title": "Practice valuation and exit-readiness check",
      "trigger": "Every two to three years, or when the owner begins seriously considering a sale, partner buy-in, or DSO affiliation within the next 24 months",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": ": standard fee-change notification practice (advance notice, honor pending estimates for a defined window, written notice to membership-plan members) — no consultancy or vendor script reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard fee-change notification practice (advance notice, honor pending estimates for a defined window, written notice to membership-plan members) — no consultancy or vendor script reproduced"
          },
          "source": ": standard fee-change notification practice (advance notice, honor pending estimates for a defined window, written notice to membership-plan members) — no consultancy or vendor script reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "own-018",
      "kind": "operational",
      "materials": [
        "updated fee schedule",
        "list of pending treatment estimates at old fees",
        "in-house membership plan roster",
        "patient notification letter/email template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "treatment-coordinator",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Office manager confirms the new fee schedule from the annual fee review (own-008) is final, and records the effective date for the change.\n\nWhy: Communication cannot start until the exact new numbers and date are locked, or patients get conflicting information.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the finalized new fee schedule and effective date",
          "why": "Communication cannot start until the exact new numbers and date are locked, or patients get conflicting information."
        },
        {
          "detail": "Treatment coordinator exports every open treatment plan or estimate quoted at the old fee schedule that has not yet been scheduled or accepted.\n\nWhy: A patient who received a written estimate has a reasonable expectation that price will hold for some window; deciding how long protects both the patient relationship and the practice.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Pull the list of patients with pending treatment estimates at the old fees",
          "why": "A patient who received a written estimate has a reasonable expectation that price will hold for some window; deciding how long protects both the patient relationship and the practice."
        },
        {
          "detail": "Owner sets a defined window (for example, estimates scheduled within 30 days of the notice keep the old fee; anything after is re-quoted at the new schedule).",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "defined-window",
              "label": "Honor old fee for a defined window, then re-quote"
            },
            {
              "goto": "s4",
              "id": "case-by-case",
              "label": "Decide case-by-case with treatment coordinator discretion"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Decide how long pending estimates are honored at the old fee"
        },
        {
          "detail": "Treatment coordinator contacts each patient on the pending-estimate list, explains the honor window, and notes in the record whether the patient scheduled within the window or the estimate was re-quoted.\n\nWhy: A documented per-patient outcome avoids a dispute later about what a patient was told and when.\n\nRecord: honor-window outcome logged per patient with a pending estimate",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Notify patients with pending estimates of the honor window",
          "why": "A documented per-patient outcome avoids a dispute later about what a patient was told and when."
        },
        {
          "detail": "Office manager exports the full list of active in-house membership plan members whose plan fee is affected by the change.\n\nWhy: Membership plan members have a standing recurring charge; a fee change to that charge needs explicit advance written notice, not just a posted sign.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the in-house membership plan roster",
          "why": "Membership plan members have a standing recurring charge; a fee change to that charge needs explicit advance written notice, not just a posted sign."
        },
        {
          "detail": "Office manager drafts a plain-language notice explaining the new fee schedule, effective date, and (for membership members) the updated plan cost, using the approved template.\n\nWhy: Clear advance notice reduces billing disputes and complaint calls at the point of service far more than a change discovered at checkout.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft the patient and member notification",
          "why": "Clear advance notice reduces billing disputes and complaint calls at the point of service far more than a change discovered at checkout."
        },
        {
          "detail": "The practice owner reviews and approves the actual drafted patient/member communication, the confirmed effective date, and the honor-window decision for pending estimates before the notice goes out to anyone.\n\nWhy: A fee increase touches every patient relationship at once; it goes out only after the owner has explicitly approved the wording that will actually be sent, not a plan for wording that doesn't exist yet.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off on the drafted notice and honor-window decision before anything is sent.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off on the drafted notice and honor-window decision before anything is sent",
          "why": "A fee increase touches every patient relationship at once; it goes out only after the owner has explicitly approved the wording that will actually be sent, not a plan for wording that doesn't exist yet."
        },
        {
          "detail": "Front desk sends the approved notice by the practice's standard patient communication channel (letter, email, or text per patient preference on file) with the required advance-notice window before the effective date.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the notice to all affected patients and membership members"
        },
        {
          "detail": "Record the send date, channel used, and count of patients/members notified, plus any bounced or undeliverable notices for follow-up.\n\nRecord: send date, channel, recipient count, undeliverable notices",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the notification send"
        },
        {
          "detail": "Office manager tracks billing disputes and membership cancellations for the first 3 days after the fee change takes effect.\n\nWhy: Early disputes are easiest to resolve while the patient still remembers receiving the notice.",
          "id": "s10",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 259200,
          "title": "Monitor for billing disputes and membership cancellations after the effective date",
          "why": "Early disputes are easiest to resolve while the patient still remembers receiving the notice."
        },
        {
          "detail": "Record the effective date, total patients/members notified, dispute count, and membership churn observed in the first week, in the owner governance log.\n\nRecord: effective date, notified count, disputes, membership churn",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the fee-change communication cycle outcome"
        },
        {
          "detail": "Fee increase communication cycle closed",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Fee increase communication cycle closed"
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "Fee increase communication to patients and membership members — The annual fee review (own-008) results in an increase and patients with pending estimates or memberships must be notified.",
      "title": "Fee increase communication to patients and membership members",
      "trigger": "The annual fee review (own-008) results in an increase and patients with pending estimates or memberships must be notified",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Dental Board of California scope-of-practice and continuing-education requirements for expanded procedures",
          "source": "Dental Board of California scope-of-practice and continuing-education requirements for expanded procedures",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "statute",
          "label": "AB 3030 (Cal. H&S §1339.75) GenAI patient-facing clinical communication disclosure with provider-reviewed exemption",
          "source": "AB 3030 (Cal. H&S §1339.75) GenAI patient-facing clinical communication disclosure with provider-reviewed exemption"
        },
        {
          "kind": "regulation",
          "label": "FTC guidance on substantiated advertising claims (truthful, non-misleading, evidence-backed) as the marketing-claims floor",
          "source": "FTC guidance on substantiated advertising claims (truthful, non-misleading, evidence-backed) as the marketing-claims floor",
          "url": "https://www.ftc.gov/business-guidance/advertising-marketing"
        },
        {
          "kind": "generic",
          "label": ": standard new-service launch checklist (training verification, consent form, fee/code setup, marketing claim review) — no consultancy or vendor playbook reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard new-service launch checklist (training verification, consent form, fee/code setup, marketing claim review) — no consultancy or vendor playbook reproduced"
          },
          "source": ": standard new-service launch checklist (training verification, consent form, fee/code setup, marketing claim review) — no consultancy or vendor playbook reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "practice-operating-systems",
      "department": "management",
      "duration_min": 480,
      "frequency": "as-needed",
      "id": "own-019",
      "kind": "operational",
      "materials": [
        "new-service business case",
        "training/certification records for the treating provider",
        "updated consent form for the new service",
        "new-service fee sheet with CDT/procedure codes",
        "marketing claim review checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "office-manager",
        "compliance-officer",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Owner documents why the service is being added (patient demand, referral leakage, revenue diversification) and the expected volume and fee range.\n\nWhy: A documented rationale keeps the launch checklist proportionate — a low-volume niche service needs less infrastructure than a core new offering.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Owner confirms the business case for the new service line",
          "why": "A documented rationale keeps the launch checklist proportionate — a low-volume niche service needs less infrastructure than a core new offering."
        },
        {
          "detail": "A licensed dentist (the owner or a designated clinical reviewer) confirms and documents the treating provider's training, certification, and that the procedure is within their licensed scope of practice, before the service is offered to any patient.\n\nWhy: Offering a procedure outside a provider's verified training or licensed scope is a patient-safety and licensure risk that a launch checklist must catch before marketing or scheduling begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off confirming the treating provider's training and scope before any patient is offered the service.",
            "role": "practice-owner or designated clinical reviewer",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off confirming the treating provider's training and scope before any patient is offered the service",
          "why": "Offering a procedure outside a provider's verified training or licensed scope is a patient-safety and licensure risk that a launch checklist must catch before marketing or scheduling begins."
        },
        {
          "detail": "Reviewer decides whether the treating provider's documented training/certification is sufficient to proceed, or whether additional training or certification is required first.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "sufficient",
              "label": "Training and scope verified as sufficient"
            },
            {
              "goto": "s14",
              "id": "gap",
              "label": "Additional training or certification required before launch"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm training is sufficient or a gap remains"
        },
        {
          "detail": "Office manager, with the treating provider, drafts a service-specific informed-consent form covering the procedure, material risks, alternatives, and expected outcomes in plain language.\n\nWhy: A generic consent form rarely covers the specific risks of a newly added procedure; a service-specific form protects both the patient's understanding and the practice.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft or update the informed-consent form for the new service",
          "why": "A generic consent form rarely covers the specific risks of a newly added procedure; a service-specific form protects both the patient's understanding and the practice."
        },
        {
          "detail": "Compliance officer reviews the consent form and any AI-assisted patient-facing educational materials for accuracy, plain-language compliance, and the required AB 3030 disclosure where GenAI-generated content reaches a patient, before anything is published or handed to a patient.\n\nWhy: Patient-facing clinical communications that use GenAI must carry the required disclosure and provider review under AB 3030; compliance confirms this before publication, not after.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review of the consent form and any patient-facing materials before publication.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review of the consent form and any patient-facing materials before publication",
          "why": "Patient-facing clinical communications that use GenAI must carry the required disclosure and provider review under AB 3030; compliance confirms this before publication, not after."
        },
        {
          "detail": "If any patient-facing educational material for the new service was AI-generated (a brochure summary, an FAQ draft), the material must carry an \"AI-generated — reviewed by a licensed provider\" (AB 3030) disclosure before it reaches a patient; compliance officer confirms this line is present or the material is withheld.\n\nWhy: This is the practice's own patient-facing GenAI obligation under AB 3030, distinct from insurer utilization-review rules that do not apply here.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the AB 3030 disclosure is present on any AI-assisted patient education content",
          "why": "This is the practice's own patient-facing GenAI obligation under AB 3030, distinct from insurer utilization-review rules that do not apply here."
        },
        {
          "detail": "Office manager sets the fee for each component of the new service and maps each to the correct procedure code, cross-checked against the practice's current fee schedule for consistency.\n\nWhy: A service launched without a clean fee/code mapping causes billing errors and claim rejections on the very first cases.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Build the fee sheet and procedure code mapping for the new service",
          "why": "A service launched without a clean fee/code mapping causes billing errors and claim rejections on the very first cases."
        },
        {
          "detail": "Marketing drafts patient-facing promotional copy for the new service; office manager and the treating provider review every claim against the marketing claim review checklist (truthful, substantiated, no guaranteed-outcome language, required disclosures present).\n\nWhy: An unsubstantiated or guaranteed-outcome marketing claim for a clinical service is both a compliance risk and a patient-expectation problem.\n\nRecord: marketing claims reviewed and approval decision per claim",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Review any marketing claims for the new service before publication",
          "why": "An unsubstantiated or guaranteed-outcome marketing claim for a clinical service is both a compliance risk and a patient-expectation problem."
        },
        {
          "detail": "Practice owner or a licensed clinical reviewer gives final sign-off on the reviewed marketing copy before it is published on any patient-facing channel.\n\nWhy: Marketing claims about a clinical service carry the same consequential weight as clinical communication and get the same sign-off discipline.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner or licensed reviewer approves marketing claims before publication.",
            "role": "practice-owner or designated clinical reviewer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner or licensed reviewer approves marketing claims before publication",
          "why": "Marketing claims about a clinical service carry the same consequential weight as clinical communication and get the same sign-off discipline."
        },
        {
          "detail": "Office manager briefs front desk and scheduling staff on how to describe the new service to inquiring patients, what to schedule, and how to route questions they cannot answer to the treating provider.\n\nWhy: Front-desk staff are the first point of contact for interested patients and need consistent, accurate language.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief front-desk and scheduling staff on the new service",
          "why": "Front-desk staff are the first point of contact for interested patients and need consistent, accurate language."
        },
        {
          "detail": "Office manager hands the completed launch checklist (training verification, consent form, fee sheet, approved marketing) to the scheduler to begin booking the first patient cases for the new service.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to scheduling for the first patient case"
        },
        {
          "detail": "Record the launch date, treating provider, training verification reference, consent form version, and fee sheet version in the owner governance log.\n\nRecord: launch date, provider, training reference, consent form version, fee sheet version",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Log the new service line launch"
        },
        {
          "detail": "New service line launch checklist closed",
          "id": "s13",
          "kind": "step",
          "role": "practice-owner",
          "title": "New service line launch checklist closed"
        },
        {
          "detail": "Owner and the treating provider set a target date for completing the required training or certification; the launch checklist pauses at this node until training-verification-gate can be re-run with a satisfactory result.\n\nWhy: Launching before a documented gap is closed is the exact risk the licensed sign-off gate exists to prevent.\n\nRecord: training gap identified, remediation plan, target completion date",
          "id": "s14",
          "kind": "step",
          "role": "practice-owner",
          "title": "Set a training-completion plan and hold the launch",
          "why": "Launching before a documented gap is closed is the exact risk the licensed sign-off gate exists to prevent."
        }
      ],
      "subclass": "owner-governance-kpis-and-reporting",
      "summary": "New service line launch (training, consent forms, fees, codes, marketing claims) — The practice decides to add a service such as implants, aligners, sleep appliances or facial injectables.",
      "title": "New service line launch (training, consent forms, fees, codes, marketing claims)",
      "trigger": "The practice decides to add a service such as implants, aligners, sleep appliances or facial injectables",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "once",
      "id": "peds-001",
      "kind": "clinical",
      "materials": [
        "knee-to-knee positioning (caregiver + provider facing each other, child's head in provider's lap)",
        "gauze",
        "soft toothbrush for demonstration",
        "fluoride varnish",
        "caregiver handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm the infant's medical history, feeding habits (bottle/breast, on-demand vs scheduled), and any prior injuries or concerns with the caregiver before seating.\n\nWhy: Feeding pattern and history drive the caries-risk conversation that follows.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Greet caregiver and infant, confirm health history",
          "why": "Feeding pattern and history drive the caries-risk conversation that follows."
        },
        {
          "detail": "Seat the caregiver and provider knee-to-knee, facing each other; lay the child supine with head in the provider's lap and legs in the caregiver's lap, caregiver holding the child's hands.\n\nWhy: The knee-to-knee position gives visibility and control for a very young, non-cooperative patient without restraint devices.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Position for the knee-to-knee exam",
          "why": "The knee-to-knee position gives visibility and control for a very young, non-cooperative patient without restraint devices."
        },
        {
          "detail": "Check soft tissue, frenum attachments, erupted/erupting teeth, occlusion, signs of early childhood caries (white-spot lesions, decalcification), and oral habits (thumb/pacifier).\n\nRecord: Exam findings entered in the chart",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the oral exam"
        },
        {
          "detail": "Any caries risk factors or findings identified?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "elevated",
              "label": "Elevated risk (white-spot lesions, frequent bottle/on-demand feeding, no fluoride exposure)"
            },
            {
              "goto": "s11",
              "id": "low",
              "label": "Low risk, no findings"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Any caries risk factors or findings identified?"
        },
        {
          "detail": "Discuss feeding modifications (no bottle propping, wean from on-demand nighttime bottle/breast once teeth erupt), fluoride exposure, and schedule a shorter recall interval.\n\nWhy: Early counseling on modifiable habits is the highest-leverage intervention at this age per the public floor.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Counsel caregiver on elevated-risk factors",
          "why": "Early counseling on modifiable habits is the highest-leverage intervention at this age per the public floor."
        },
        {
          "detail": "The treating dentist reviews the exam findings and risk tier and signs off on the plan before the hygienist applies fluoride varnish.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on exam findings and plan before treatment.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on exam findings and plan before treatment"
        },
        {
          "detail": "Apply fluoride varnish to erupted teeth per the public-floor recommendation when caries risk or eruption pattern indicates it; note any caregiver decline.\n\nWhy: Varnish reduces early childhood caries incidence at this age per AAPD guidance.\n\nRecord: Varnish applied (or declined) noted in the chart",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Apply fluoride varnish if indicated",
          "why": "Varnish reduces early childhood caries incidence at this age per AAPD guidance."
        },
        {
          "detail": "Front desk schedules the next recall at the interval the dentist specified — 6 months routine, 3 months if elevated risk.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule recall"
        },
        {
          "detail": "Office manager logs whether varnish was applied and the risk tier assigned into the practice's tracking sheet.\n\nRecord: Risk tier and varnish status logged",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log visit outcome"
        },
        {
          "detail": "First visit complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "First visit complete"
        },
        {
          "detail": "Demonstrate wiping/brushing technique with a soft brush, discuss teething, non-nutritive habits, and injury prevention.",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Counsel caregiver on routine home care"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "First dental visit by age one — knee-to-knee exam and caregiver counseling — An infant or toddler presents for a first visit.",
      "title": "First dental visit by age one — knee-to-knee exam and caregiver counseling",
      "trigger": "An infant or toddler presents for a first visit",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "peds-002",
      "kind": "clinical",
      "materials": [
        "age-appropriate demonstration items for tell-show-do",
        "distraction media (video, toy) if used",
        "nitrous oxide equipment if escalation reaches that tier"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Observe the child's affect, verbal responses and body language on seating; ask the caregiver what has helped at prior medical/dental visits.\n\nWhy: Starting technique should match the child's developmental stage and known triggers, not a one-size approach.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Assess the child's cooperation level",
          "why": "Starting technique should match the child's developmental stage and known triggers, not a one-size approach."
        },
        {
          "detail": "Tell the child in simple words what will happen, show the instrument or step on a finger/model first, then do the step exactly as shown.\n\nWhy: Tell-show-do is the first-line communicative technique because it removes surprise, the main driver of dental fear at this age.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Tell-show-do",
          "why": "Tell-show-do is the first-line communicative technique because it removes surprise, the main driver of dental fear at this age."
        },
        {
          "detail": "Did the child cooperate after tell-show-do?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes1",
              "label": "Yes — proceed with treatment"
            },
            {
              "goto": "s7",
              "id": "no1",
              "label": "No — escalate technique"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Did the child cooperate after tell-show-do?"
        },
        {
          "detail": "Continue the planned procedure using the technique that achieved cooperation, reinforcing with praise throughout.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed with planned treatment"
        },
        {
          "detail": "Note which rung of the ladder resolved the visit (or that escalation was needed) in the chart for continuity at future visits.\n\nRecord: Behavior guidance technique and outcome logged",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Document the technique used and outcome"
        },
        {
          "detail": "Behavior guidance episode resolved",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Behavior guidance episode resolved"
        },
        {
          "detail": "Introduce distraction (video, counting, a story) and verbal praise for small successes.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Add distraction and positive reinforcement"
        },
        {
          "detail": "Did distraction resolve the uncooperative behavior?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes2",
              "label": "Yes — proceed with treatment"
            },
            {
              "goto": "s9",
              "id": "no2",
              "label": "No — escalate to voice control and caregiver adjustment"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Did distraction resolve the uncooperative behavior?"
        },
        {
          "detail": "Use calm, firm, brief verbal direction; decide whether caregiver presence is helping or should be adjusted (some children do better with caregiver visible, some with caregiver stepping back).\n\nWhy: Voice control re-establishes communication before any physical or pharmacologic escalation is considered.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Voice control and caregiver positioning",
          "why": "Voice control re-establishes communication before any physical or pharmacologic escalation is considered."
        },
        {
          "detail": "Is the child now cooperative, or is urgent treatment still blocked?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "cooperative",
              "label": "Cooperative now — proceed with treatment"
            },
            {
              "goto": "s11",
              "id": "blocked",
              "label": "Still blocked and treatment is urgent"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the child now cooperative, or is urgent treatment still blocked?"
        },
        {
          "detail": "The treating dentist decides, and documents the clinical reason, whether to move to protective stabilization (peds-003) or refer for pharmacologic behavior guidance (peds-010/peds-011); this decision is never made by non-licensed staff.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed decision to escalate beyond communicative guidance.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed decision to escalate beyond communicative guidance"
        },
        {
          "detail": "Route to protective stabilization (peds-003) or sedation/GA referral (peds-010/peds-011) per the dentist's decision.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the escalation protocol"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Behavior guidance ladder — tell-show-do, distraction, voice control, caregiver presence, escalation criteria — A child is anxious or uncooperative in the chair.",
      "title": "Behavior guidance ladder — tell-show-do, distraction, voice control, caregiver presence, escalation criteria",
      "trigger": "A child is anxious or uncooperative in the chair",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "peds-003",
      "kind": "clinical",
      "materials": [
        "stabilization device (e.g. full-body pediatric immobilization wrap or mouth prop) sized to the child",
        "written consent form specific to protective stabilization",
        "timer for monitoring intervals"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Is protective stabilization clinically indicated?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "indicated",
              "label": "Yes — urgent treatment needed and communicative guidance alone is insufficient"
            },
            {
              "goto": "s10",
              "id": "not-indicated",
              "label": "No — return to communicative guidance or reschedule"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "dentist",
          "title": "Is protective stabilization clinically indicated?"
        },
        {
          "detail": "The dentist explains the indication, the specific device, expected duration and the caregiver's right to have it removed at any time; caregiver signs a written consent specific to protective stabilization before it is used.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Written informed consent before any stabilization is applied.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "caregiver",
          "title": "Written informed consent before any stabilization is applied"
        },
        {
          "detail": "Select and apply the smallest, least restrictive device that allows treatment to proceed safely; check circulation and comfort immediately after application.\n\nWhy: Least-restrictive-first minimizes distress and physical risk while still enabling urgent care.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Apply the least restrictive effective device",
          "why": "Least-restrictive-first minimizes distress and physical risk while still enabling urgent care."
        },
        {
          "detail": "Check and log the child's circulation, breathing, and stabilization fit at this interval; loosen or remove immediately if distress is disproportionate. This single check represents one pass of a check that recurs every few minutes for as long as the device stays on, including while treatment is underway — it is not a one-time gate before treatment starts.\n\nWhy: Ongoing monitoring, repeated for the entire time a child is restrained (not just once before treatment), is what makes stabilization a safety-bounded technique rather than an unsupervised restraint.\n\nRecord: Monitoring checks logged with time and findings",
          "id": "s4",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 300,
          "title": "Recurring monitoring check (repeats every few minutes throughout use)",
          "why": "Ongoing monitoring, repeated for the entire time a child is restrained (not just once before treatment), is what makes stabilization a safety-bounded technique rather than an unsupervised restraint."
        },
        {
          "detail": "Perform the treatment that required stabilization, working efficiently to minimize total time in the device; the assistant keeps watching circulation, breathing and fit throughout this step, not only at the last monitoring check.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Continue the urgent treatment"
        },
        {
          "detail": "Is the urgent treatment finished and ready for device removal?",
          "forks": [
            {
              "goto": "s4",
              "id": "still-treating",
              "label": "Not yet — treatment continues, run another monitoring check before proceeding further"
            },
            {
              "advised": true,
              "goto": "s7",
              "id": "finished",
              "label": "Yes — treatment is complete, move to removal"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the urgent treatment finished and ready for device removal?"
        },
        {
          "detail": "Remove the stabilization device as soon as treatment allows, check skin/circulation one final time, and reassure and praise the child.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Remove the device and reassure the child"
        },
        {
          "detail": "Chart the clinical indication, that consent was obtained, total duration of use, and a summary of monitoring findings.\n\nRecord: Indication, consent reference, duration and monitoring summary in the chart",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document indication, consent, duration and monitoring"
        },
        {
          "detail": "Protective stabilization episode complete and documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Protective stabilization episode complete and documented"
        },
        {
          "detail": "Stabilization not used — care continues via behavior guidance ladder",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Stabilization not used — care continues via behavior guidance ladder"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Protective stabilization — indications, written consent, monitoring and documentation — Urgent treatment cannot be completed safely with communicative guidance alone.",
      "title": "Protective stabilization — indications, written consent, monitoring and documentation",
      "trigger": "Urgent treatment cannot be completed safely with communicative guidance alone",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "peds-004",
      "kind": "clinical",
      "materials": [
        "caries-risk assessment form",
        "fluoride varnish or other topical fluoride",
        "sealant materials if indicated",
        "diet/habit questionnaire"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Review diet/snacking frequency, fluoride exposure (water source, toothpaste use), plaque/hygiene level, prior caries history, and any special health care needs.\n\nRecord: Risk assessment form completed in the chart",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Complete the caries risk assessment"
        },
        {
          "detail": "Assign a risk tier",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "elevated",
              "label": "Elevated/high risk"
            },
            {
              "goto": "s12",
              "id": "low-risk",
              "label": "Low risk"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Assign a risk tier"
        },
        {
          "detail": "Prescribe more frequent fluoride varnish application, shorten recall interval (typically 3 months), and target diet counseling to the specific habit identified.\n\nWhy: Intervention intensity should scale with measured risk rather than applying the same plan to every patient.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Build the elevated-risk prevention plan",
          "why": "Intervention intensity should scale with measured risk rather than applying the same plan to every patient."
        },
        {
          "detail": "Discuss frequency of sugared snacks/drinks, bottle/sippy-cup habits, and non-nutritive sucking habits with the caregiver, tying advice to the specific findings above.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Diet and habit counseling"
        },
        {
          "detail": "The treating dentist reviews and signs off on the assigned risk tier and prevention plan before sealants or fluoride are applied.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the risk tier and plan before treatment.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the risk tier and plan before treatment"
        },
        {
          "detail": "Are permanent molars erupted and sealant-eligible?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "eligible",
              "label": "Yes — place sealants"
            },
            {
              "goto": "s8",
              "id": "not-eligible",
              "label": "No — not yet erupted or already restored"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Are permanent molars erupted and sealant-eligible?"
        },
        {
          "detail": "Isolate, etch, rinse, dry, and place sealant material on eligible occlusal surfaces; check occlusion after placement.\n\nRecord: Sealants placed logged by tooth",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Place pit-and-fissure sealants"
        },
        {
          "detail": "Apply the fluoride vehicle indicated for the assigned risk tier.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Apply fluoride"
        },
        {
          "detail": "Front desk books the next recall at the interval the dentist assigned.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule next recall per risk tier"
        },
        {
          "detail": "Office manager logs the assigned risk tier, sealants placed and fluoride applied into the practice's tracking sheet.\n\nRecord: Risk tier and interventions logged",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the risk tier and interventions"
        },
        {
          "detail": "Prevention plan complete",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Prevention plan complete"
        },
        {
          "detail": "Standard fluoride varnish at recall and routine 6-month interval; reinforce home care.",
          "id": "s12",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm routine prevention plan"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Pediatric caries risk assessment, fluoride, diet and sealant plan — Every pediatric recall or new-patient visit.",
      "title": "Pediatric caries risk assessment, fluoride, diet and sealant plan",
      "trigger": "Every pediatric recall or new-patient visit",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-use",
      "id": "peds-005",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "rubber dam isolation",
        "pulpotomy medicament per office protocol",
        "stainless steel crown kit (sized selection)",
        "cement"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm via history, clinical exam and radiograph that the pulp is vital, caries is deep but reversible pulpitis or normal pulp, and there is no abscess, mobility or furcation radiolucency.\n\nWhy: Pulpotomy is indicated only for a vital pulp without irreversible infection; misdiagnosis leads to a failing restoration.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm diagnosis and vitality",
          "why": "Pulpotomy is indicated only for a vital pulp without irreversible infection; misdiagnosis leads to a failing restoration."
        },
        {
          "detail": "Explain the procedure, alternatives (extraction with space maintenance, pulpectomy, no treatment), and risks; obtain caregiver signature before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent for pulpotomy and crown.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "caregiver",
          "title": "Informed consent for pulpotomy and crown"
        },
        {
          "detail": "Administer local anesthetic appropriate to the tooth and the child's weight-based maximum dose; confirm profound anesthesia before proceeding.\n\nWhy: Weight-based dosing is the public-floor safety standard for pediatric local anesthesia (DOCS/TECHNICAL_PROTOCOLS.md §pediatric dosing).",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia",
          "why": "Weight-based dosing is the public-floor safety standard for pediatric local anesthesia (DOCS/TECHNICAL_PROTOCOLS.md §pediatric dosing)."
        },
        {
          "detail": "Isolate the tooth with a rubber dam to maintain a dry field and protect the airway from debris.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Place rubber dam isolation"
        },
        {
          "detail": "Remove all caries, gain access to the pulp chamber, and amputate the coronal pulp.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Access pulp chamber and remove caries"
        },
        {
          "detail": "Is hemostasis achieved and radicular pulp healthy?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes-hemo",
              "label": "Yes — proceed with pulpotomy medicament"
            },
            {
              "goto": "s13",
              "id": "no-hemo",
              "label": "No — bleeding does not stop or pulp appears necrotic, reconsider diagnosis"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is hemostasis achieved and radicular pulp healthy?"
        },
        {
          "detail": "Apply the office's selected pulpotomy medicament to the radicular pulp stumps per its manufacturer directions.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Apply pulpotomy medicament"
        },
        {
          "detail": "Place a base material over the pulp chamber and reduce tooth structure as needed to receive a stainless steel crown.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Place base and build up for crown prep"
        },
        {
          "detail": "Select the smallest crown that fully seats, trim and crimp margins as needed, and cement.\n\nRecord: Crown size and procedure details logged",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Select, fit and cement the stainless steel crown"
        },
        {
          "detail": "Instruct caregiver on numbness precautions (avoid biting cheek/lip until anesthesia wears off), normal chewing once settled, and warning signs to call about (swelling, pain, mobility).",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Front desk schedules a follow-up recall visit to confirm the tooth remains asymptomatic.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule follow-up recall"
        },
        {
          "detail": "Procedure complete",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Procedure complete"
        },
        {
          "detail": "If radicular pulp findings indicate necrosis rather than a vital pulp, stop and proceed under the pulpectomy protocol (peds-006) instead.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Route to pulpectomy protocol"
        },
        {
          "detail": "Chart the intraoperative finding and the switch to pulpectomy.\n\nRecord: Diagnosis change and rerouted plan noted",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Document the change in diagnosis and plan"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Primary molar pulpotomy and stainless steel crown — Deep caries into the pulp of a vital primary molar with no abscess.",
      "title": "Primary molar pulpotomy and stainless steel crown",
      "trigger": "Deep caries into the pulp of a vital primary molar with no abscess",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 50,
      "frequency": "per-use",
      "id": "peds-006",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "rubber dam isolation",
        "small endodontic files sized for primary canals",
        "resorbable filling material",
        "stainless steel crown kit"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm via history (spontaneous pain, swelling), clinical exam and radiograph that the pulp is necrotic or irreversibly inflamed, the tooth is structurally restorable, and there is enough root remaining to retain the tooth.\n\nWhy: Pulpectomy is only appropriate when the tooth is worth retaining for space and can be adequately obturated.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm necrotic pulp diagnosis and restorability",
          "why": "Pulpectomy is only appropriate when the tooth is worth retaining for space and can be adequately obturated."
        },
        {
          "detail": "Explain the procedure, alternatives (extraction with space maintenance), and risks including possible future extraction if it fails; obtain caregiver signature.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent for pulpectomy.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "caregiver",
          "title": "Informed consent for pulpectomy"
        },
        {
          "detail": "Administer local anesthetic appropriate to the tooth and the child's weight-based maximum dose; confirm profound anesthesia before proceeding.\n\nWhy: Weight-based dosing is the public-floor safety standard for pediatric local anesthesia.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia",
          "why": "Weight-based dosing is the public-floor safety standard for pediatric local anesthesia."
        },
        {
          "detail": "Isolate the tooth with a rubber dam for a clean field and airway protection during canal instrumentation.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Place rubber dam isolation"
        },
        {
          "detail": "Gain access, remove necrotic pulp tissue from the canals with files sized for primary root canals, working short of the radiographic apex to avoid injuring the permanent successor.\n\nWhy: Overinstrumentation past the apex risks damaging the developing permanent tooth bud beneath.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Access, clean and shape canals",
          "why": "Overinstrumentation past the apex risks damaging the developing permanent tooth bud beneath."
        },
        {
          "detail": "Irrigate canals to remove debris and disinfect, then dry with paper points before filling.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Irrigate and dry canals"
        },
        {
          "detail": "Fill each canal with a resorbable filling material sized so it resorbs on the same timeline as the primary tooth's own roots.\n\nWhy: A non-resorbable filling would block or delay normal exfoliation and eruption of the permanent successor.\n\nRecord: Filling material and canals treated logged",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Fill canals with resorbable material",
          "why": "A non-resorbable filling would block or delay normal exfoliation and eruption of the permanent successor."
        },
        {
          "detail": "Seal the access, build up remaining structure, and place a stainless steel crown for long-term coronal protection.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Restore access and place a stainless steel crown"
        },
        {
          "detail": "Instruct caregiver on numbness precautions, expected mild soreness, and warning signs to call about (increasing pain, swelling, drainage).",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Front desk schedules a follow-up visit including a radiograph to confirm healing and normal resorption progress.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule follow-up recall with radiograph"
        },
        {
          "detail": "Procedure complete",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Procedure complete"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Primary tooth pulpectomy with resorbable filling — A necrotic primary tooth worth retaining for space.",
      "title": "Primary tooth pulpectomy with resorbable filling",
      "trigger": "A necrotic primary tooth worth retaining for space",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-use",
      "id": "peds-007",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "extraction forceps/elevators sized for primary teeth",
        "gauze",
        "space maintainer impression materials if indicated"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm via exam and radiograph that the tooth is non-restorable or extraction is otherwise indicated (severe infection unresponsive to pulp therapy, resorption failure, etc.).",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm extraction is indicated"
        },
        {
          "detail": "Explain the procedure, alternatives, and the space-maintenance discussion to follow; obtain caregiver signature before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent for extraction.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "caregiver",
          "title": "Informed consent for extraction"
        },
        {
          "detail": "Administer local anesthetic at a weight-based dose, confirm profound anesthesia, then extract the tooth with minimal trauma to adjacent structures and the underlying successor.\n\nWhy: The permanent successor tooth bud sits close to the primary root apex — atraumatic technique protects it.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Anesthetize and extract",
          "why": "The permanent successor tooth bud sits close to the primary root apex — atraumatic technique protects it."
        },
        {
          "detail": "Have the child bite on gauze until bleeding stops; confirm socket is stable before dismissing.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Achieve hemostasis"
        },
        {
          "detail": "How far is the permanent successor from eruption?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "far",
              "label": "Successor is far from eruption (early loss) — space maintenance indicated"
            },
            {
              "goto": "s10",
              "id": "close",
              "label": "Successor is close to eruption — space maintenance not needed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "How far is the permanent successor from eruption?"
        },
        {
          "detail": "Take an impression (or scan) of the arch and send the prescription to the lab for a band-and-loop or lingual arch maintainer per the dentist's design.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Take impression and order the space maintainer"
        },
        {
          "detail": "Instruct caregiver on post-extraction care and that a follow-up visit is needed to deliver the space maintainer once it returns from the lab (see peds-008).",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-op instructions and schedule delivery"
        },
        {
          "detail": "Chart the extraction, the estimated eruption timing for the successor, and the decision whether a maintainer was ordered.\n\nRecord: Extraction and space-maintenance decision logged with rationale",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the space-maintenance decision and rationale"
        },
        {
          "detail": "Extraction and space-maintenance decision complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Extraction and space-maintenance decision complete"
        },
        {
          "detail": "Instruct caregiver on post-extraction care (soft diet, avoid the area, warning signs to call about); note no maintainer is needed given imminent eruption.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-op instructions"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Primary tooth extraction and space-maintainer decision — A non-restorable primary tooth, or premature loss with the successor far from eruption.",
      "title": "Primary tooth extraction and space-maintainer decision",
      "trigger": "A non-restorable primary tooth, or premature loss with the successor far from eruption",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6 (in-repo pediatric basis)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "peds-008",
      "kind": "clinical",
      "materials": [
        "fabricated space maintainer from the lab",
        "cement",
        "articulating paper",
        "recall tracking sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Seat the fabricated appliance and check fit, tissue contact, and that it does not impinge on erupting teeth or soft tissue.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Try in the space maintainer"
        },
        {
          "detail": "Does the appliance fit correctly?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "fits",
              "label": "Yes — proceed to cementation"
            },
            {
              "goto": "s11",
              "id": "no-fit",
              "label": "No — send back to lab for adjustment"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the appliance fit correctly?"
        },
        {
          "detail": "The treating dentist confirms fit and design are correct and signs off before the appliance is permanently cemented, since cementation is not easily reversible.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before permanent cementation.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before permanent cementation"
        },
        {
          "detail": "Cement the space maintainer per the cement manufacturer's technique, remove excess cement, and check occlusion with articulating paper.\n\nRecord: Appliance delivered and cemented, occlusion checked",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Cement the appliance"
        },
        {
          "detail": "Instruct caregiver on cleaning around the appliance, foods to avoid (sticky candy that can dislodge it), and to call if it becomes loose or is lost.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Give home-care instructions"
        },
        {
          "detail": "Front desk schedules recurring recall checks at the interval the dentist set, continuing until the permanent successor erupts.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule recall monitoring visits"
        },
        {
          "detail": "At each recall, verify the appliance is intact and in place, check radiographically or clinically for successor eruption, and remove the appliance once the successor is emerging through it.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Check appliance and eruption status at each recall"
        },
        {
          "detail": "Has the permanent successor begun erupting?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "erupting",
              "label": "Yes — remove the appliance"
            },
            {
              "goto": "s6",
              "id": "not-yet",
              "label": "Not yet — continue monitoring at next recall"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Has the permanent successor begun erupting?"
        },
        {
          "detail": "Remove the space maintainer and log that space maintenance is complete now that the successor is erupting.\n\nRecord: Appliance removal and eruption status logged",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Remove appliance and log completion"
        },
        {
          "detail": "Space maintenance complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Space maintenance complete"
        },
        {
          "detail": "Lab liaison sends the appliance back with specific adjustment notes and reschedules the delivery visit.",
          "id": "s11",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Return appliance to lab for adjustment"
        },
        {
          "detail": "Delivery rescheduled pending lab adjustment",
          "id": "s12",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Delivery rescheduled pending lab adjustment"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Space maintainer delivery, cementation and recall monitoring — A band-and-loop or lingual arch is returned from the lab.",
      "title": "Space maintainer delivery, cementation and recall monitoring",
      "trigger": "A band-and-loop or lingual arch is returned from the lab",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "open_standard",
          "label": "IADT primary-tooth trauma guidelines",
          "source": "IADT primary-tooth trauma guidelines",
          "url": "https://www.iadt-dentaltrauma.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §7 (in-repo emergency triage basis) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md §7 (in-repo emergency triage basis)"
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §7 (in-repo emergency triage basis) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "peds-009",
      "kind": "clinical",
      "materials": [
        "gauze",
        "cold compress",
        "periapical x-ray unit",
        "topical/local anesthetic kit",
        "soft diet handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "caregiver",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the child is unconscious, has uncontrolled bleeding, a suspected head/neck/facial fracture, or loss of consciousness at the time of injury, call 911 immediately and do not proceed with dental assessment until EMS has cleared the scene.\n\nWhy: Life-threatening head or airway injury always outranks a dental finding; a knocked-out or displaced baby tooth is never the first thing evaluated in a trauma call.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Rule out a medical emergency before anything else.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Rule out a medical emergency before anything else",
          "why": "Life-threatening head or airway injury always outranks a dental finding; a knocked-out or displaced baby tooth is never the first thing evaluated in a trauma call."
        },
        {
          "detail": "Ask what happened, when, whether the child lost consciousness, whether a tooth is missing/loose/displaced, and whether there is bleeding that will not stop with gauze pressure. Book an emergency slot the same day.\n\nWhy: Primary-tooth trauma timing affects the treatment decision (e.g. intrusion direction, whether to watch or intervene), so delay changes the plan.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Triage the call and get the child seen same-day",
          "why": "Primary-tooth trauma timing affects the treatment decision (e.g. intrusion direction, whether to watch or intervene), so delay changes the plan."
        },
        {
          "detail": "Use tell-show-do at a level suited to the child's age; keep the caregiver present for a young child per the age-based communication ladder.\n\nWhy: A frightened, crying child is harder to examine safely and accurately.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Welcome the child and caregiver calmly",
          "why": "A frightened, crying child is harder to examine safely and accurately."
        },
        {
          "detail": "Briefly re-ask the same red-flag questions covered on the phone — has the child lost consciousness, vomited, become unusually drowsy, or shown a behavior change since the fall — because symptoms can evolve in the hours between the call and arrival.\n\nWhy: A same-day trauma visit can have a gap of hours between the initial phone screen and arrival; a child whose symptoms evolved in that window must be re-screened at check-in, not assumed still clear from the earlier call.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Re-screen for red-flag injury signs before starting the dental history",
          "why": "A same-day trauma visit can have a gap of hours between the initial phone screen and arrival; a child whose symptoms evolved in that window must be re-screened at check-in, not assumed still clear from the earlier call."
        },
        {
          "detail": "Are any red-flag signs present now?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "opt-clear",
              "label": "No red flags now — proceed with the dental history and exam"
            },
            {
              "goto": "s1",
              "id": "opt-flag",
              "label": "A red flag is present now (loss of consciousness, vomiting, worsening drowsiness or behavior change) — treat as a medical emergency"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Are any red-flag signs present now?"
        },
        {
          "detail": "Document mechanism of injury, time since injury, tetanus status if a dirty wound is present, prior dental history, and any change in consciousness, vomiting, or behavior since the fall.\n\nWhy: Time-since-injury and mechanism drive both the treatment decision and any mandated-reporting screen.\n\nRecord: trauma history in the chart: mechanism, time, symptoms since injury",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Take a focused trauma history",
          "why": "Time-since-injury and mechanism drive both the treatment decision and any mandated-reporting screen."
        },
        {
          "detail": "If the story does not match the injury, or the injury pattern looks non-accidental, follow the separate mandated-reporting protocol (patient-rights class) rather than deciding this alone.\n\nWhy: All dental providers are mandated reporters; a trauma visit is one of the settings where this comes up.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Check the history is consistent with the injury pattern",
          "why": "All dental providers are mandated reporters; a trauma visit is one of the settings where this comes up."
        },
        {
          "detail": "Check tooth mobility and displacement direction, soft-tissue lacerations, occlusal interference, and take a periapical radiograph of the involved tooth and surrounding bone.\n\nWhy: The type of luxation and any bone injury determine the treatment path.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "periapical x-ray unit"
          ],
          "role": "dentist",
          "title": "Examine the tooth, soft tissue, and occlusion",
          "why": "The type of luxation and any bone injury determine the treatment path."
        },
        {
          "detail": "The treating dentist confirms the injury classification and radiographic findings in person before any extraction, observation-only, or intrusion-management decision is finalized — an assistant's or hygienist's read of the film is never the deciding read.\n\nWhy: Whether to extract, observe, or wait on a primary tooth changes the developing permanent tooth's outcome, so the consequential call stays with the licensed provider.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed dentist signs off on the trauma classification before treatment.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed dentist signs off on the trauma classification before treatment",
          "why": "Whether to extract, observe, or wait on a primary tooth changes the developing permanent tooth's outcome, so the consequential call stays with the licensed provider."
        },
        {
          "detail": "Classify as concussion/subluxation (no significant displacement), luxation (displaced but present), intrusion, or avulsion (tooth entirely out of the socket).\n\nWhy: This is a classification driven entirely by the exam finding, not a preference — 'advised' on concussion/subluxation only marks the default rendering order and does not mean that outcome is clinically recommended over the others; the actual injury type on exam determines the correct branch.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "opt-concussion",
              "label": "Concussion or subluxation — observe, soft diet, monitor"
            },
            {
              "goto": "s16",
              "id": "opt-luxation",
              "label": "Luxation with occlusal interference or mobility — may need extraction if severely mobile or interfering with occlusion"
            },
            {
              "goto": "s17",
              "id": "opt-intrusion",
              "label": "Intrusion — usually observed for spontaneous re-eruption unless it threatens the permanent successor"
            },
            {
              "goto": "s18",
              "id": "opt-avulsion",
              "label": "Avulsion — do NOT replant a primary tooth"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "title": "Classify the injury and choose the management path",
          "why": "This is a classification driven entirely by the exam finding, not a preference — 'advised' on concussion/subluxation only marks the default rendering order and does not mean that outcome is clinically recommended over the others; the actual injury type on exam determines the correct branch."
        },
        {
          "detail": "No active treatment beyond soft diet for 1–2 weeks and monitoring for color change, mobility increase, or swelling at follow-up.\n\nWhy: Most primary-tooth concussions and mild subluxations resolve without intervention.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Manage a concussion/subluxation conservatively",
          "why": "Most primary-tooth concussions and mild subluxations resolve without intervention."
        },
        {
          "detail": "Cover soft diet duration, oral hygiene around the area, pain control, and specific signs to call about immediately: increasing swelling, fever, drainage/pimple on the gum, or color change to gray/dark.\n\nWhy: Trauma sequelae (infection, discoloration, ankylosis) can appear days to weeks later, after the family has left the office.\n\nRecord: written instructions given, reviewed with caregiver",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Give the caregiver written home-care and warning-sign instructions",
          "why": "Trauma sequelae (infection, discoloration, ankylosis) can appear days to weeks later, after the family has left the office."
        },
        {
          "detail": "Book a follow-up around 1–2 weeks, then again at intervals through eruption of the permanent successor, watching for infection, ankylosis, or effects on the permanent tooth.\n\nWhy: Primary trauma sequelae can surface long after the injury, so a single visit is not the end of monitoring.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule short- and long-interval follow-up",
          "why": "Primary trauma sequelae can surface long after the injury, so a single visit is not the end of monitoring."
        },
        {
          "detail": "Chart the classification, treatment rendered or deferred, radiograph findings, caregiver instructions given, and the follow-up schedule; attach any consented photographs.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the trauma record"
        },
        {
          "detail": "Trauma visit complete",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Trauma visit complete"
        },
        {
          "detail": "If the tooth interferes with the bite or is severely mobile, extraction is often preferred over repositioning, because forcing a primary tooth back risks the permanent successor beneath it; if mildly displaced and not interfering, observe.\n\nWhy: Repositioning primary teeth carries more risk to the developing permanent tooth than in adult trauma.",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Manage a displaced but retained primary tooth",
          "why": "Repositioning primary teeth carries more risk to the developing permanent tooth than in adult trauma."
        },
        {
          "detail": "Most intruded primary incisors are left to re-erupt spontaneously over weeks to months with monitoring; extraction is reserved for intrusion that is driven into or clearly threatening the permanent tooth germ on the radiograph.\n\nWhy: Primary-tooth intrusion management differs from permanent-tooth intrusion precisely because of the successor tooth underneath.",
          "id": "s17",
          "kind": "step",
          "role": "dentist",
          "title": "Manage an intruded primary tooth",
          "why": "Primary-tooth intrusion management differs from permanent-tooth intrusion precisely because of the successor tooth underneath."
        },
        {
          "detail": "Do not attempt to replant an avulsed primary tooth under any circumstance; confirm the entire tooth is accounted for (not intruded/aspirated) and, if the whole tooth cannot be located, discuss a chest/abdominal film with the child's physician to rule out aspiration or swallowing.\n\nWhy: Replanting a primary tooth risks fusing to or damaging the permanent successor; this is the one point in the primary trauma literature stated as an absolute.",
          "id": "s18",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm no replantation of an avulsed primary tooth",
          "why": "Replanting a primary tooth risks fusing to or damaging the permanent successor; this is the one point in the primary trauma literature stated as an absolute."
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Primary tooth trauma — luxation, intrusion, avulsion (no replantation) — A young child falls and injures a primary tooth.",
      "title": "Primary tooth trauma — luxation, intrusion, avulsion (no replantation)",
      "trigger": "A young child falls and injures a primary tooth",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "open_standard",
          "label": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "source": "AAPD/AAP monitoring guideline for pediatric sedation (open)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6.1 (in-repo pediatric basis: nitrous oxide requires in-office protocol and monitoring)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6.1 (in-repo pediatric basis: nitrous oxide requires in-office protocol and monitoring)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "peds-010",
      "kind": "clinical",
      "materials": [
        "nitrous oxide/oxygen delivery unit with scavenging",
        "nasal hood (child-sized)",
        "pulse oximeter",
        "written consent form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Review the child's medical history for nasal obstruction, chronic respiratory disease (e.g. severe asthma, COPD-type conditions), pregnancy in a caregiver present, recent ear/sinus surgery, and confirm ASA I or ASA II status.\n\nWhy: Nitrous is a minimal-sedation option only appropriate for medically low-risk children; nasal breathing is required for it to work at all.\n\nRecord: medical history review and ASA classification",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Screen medical history and ASA classification",
          "why": "Nitrous is a minimal-sedation option only appropriate for medically low-risk children; nasal breathing is required for it to work at all."
        },
        {
          "detail": "Confirm the child is an appropriate candidate",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-eligible",
              "label": "ASA I/II, no contraindication — proceed"
            },
            {
              "goto": "s12",
              "id": "opt-not-eligible",
              "label": "ASA III+ or contraindication present — refer for moderate sedation/GA instead"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Confirm the child is an appropriate candidate"
        },
        {
          "detail": "Explain the procedure, expected effect, risks (nausea, rare over-sedation, and diffusion hypoxia/grogginess on standing if the child is not given an oxygen washout at the end), and alternatives in plain language; the caregiver signs before nitrous is administered.\n\nWhy: Sedating a minor requires documented informed consent from the legal caregiver, not implied consent from showing up for the appointment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain written informed consent from the caregiver.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "caregiver",
          "title": "Obtain written informed consent from the caregiver",
          "why": "Sedating a minor requires documented informed consent from the legal caregiver, not implied consent from showing up for the appointment."
        },
        {
          "detail": "Use tell-show-do to introduce the nasal hood as a 'nose that smells like a balloon,' let the child hold and smell it if helpful, and use calm, firm voice control.\n\nWhy: Nitrous works better and settles faster in a child who has already been coached through the behavior-guidance ladder rather than one who is startled by the mask.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Try tell-show-do and voice control before administering",
          "why": "Nitrous works better and settles faster in a child who has already been coached through the behavior-guidance ladder rather than one who is startled by the mask."
        },
        {
          "detail": "Start with 100% oxygen for 1–2 minutes, then titrate nitrous upward in small increments while watching for signs of adequate sedation (relaxed posture, slowed response) without over-sedation (slurred speech, spontaneous eye closure).\n\nWhy: Titration to effect, not a fixed dose, is how minimal sedation stays minimal.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "nitrous oxide/oxygen delivery unit with scavenging"
          ],
          "role": "dentist",
          "title": "Place the nasal hood and titrate nitrous concentration",
          "why": "Titration to effect, not a fixed dose, is how minimal sedation stays minimal."
        },
        {
          "detail": "Watch respiratory rate, color, and responsiveness continuously; use pulse oximetry per the office's minimal-sedation monitoring standard; have an assistant dedicated to observation, separate from the operator.\n\nWhy: Continuous observation is how an over-sedation episode is caught early enough to correct with oxygen.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "pulse oximeter"
          ],
          "role": "assistant",
          "title": "Monitor continuously throughout treatment",
          "why": "Continuous observation is how an over-sedation episode is caught early enough to correct with oxygen."
        },
        {
          "detail": "Perform the procedure the child was scheduled for while sedation is maintained at a steady, comfortable level.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the planned dental treatment"
        },
        {
          "detail": "Switch to 100% oxygen for at least 3–5 minutes before removing the hood, and keep the child seated and observed until alert, coordinated, and back to their pre-sedation baseline.\n\nWhy: Washout with oxygen clears residual nitrous and prevents diffusion hypoxia on standing up too soon.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Deliver 100% oxygen at the end and observe recovery",
          "why": "Washout with oxygen clears residual nitrous and prevents diffusion hypoxia on standing up too soon."
        },
        {
          "detail": "Confirm the child can walk steadily and respond normally, then give the caregiver written instructions to keep the child resting quietly for the rest of the day and to call the office with any concerns.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm readiness for discharge and give caregiver instructions"
        },
        {
          "detail": "Chart ASA status, consent, nitrous concentration range used, vital-sign/monitoring notes, procedure performed, and recovery time to baseline.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the sedation record"
        },
        {
          "detail": "Sedation visit complete",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Sedation visit complete"
        },
        {
          "detail": "Route to the pediatric moderate-sedation-or-GA-referral protocol rather than proceeding with nitrous.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the sedation/GA referral protocol"
        },
        {
          "detail": "Child referred for moderate sedation/GA instead",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Child referred for moderate sedation/GA instead"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Nitrous oxide/oxygen minimal sedation for a child — A child needs anxiety reduction and meets ASA I/II criteria.",
      "title": "Nitrous oxide/oxygen minimal sedation for a child",
      "trigger": "A child needs anxiety reduction and meets ASA I/II criteria",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "open_standard",
          "label": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "source": "AAPD/AAP monitoring guideline for pediatric sedation (open)"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.506 (provider-to-provider referral communication)",
          "source": "HIPAA 45 CFR 164.506 (provider-to-provider referral communication)",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-E/section-164.506"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "peds-011",
      "kind": "clinical",
      "materials": [
        "referral form",
        "treatment plan summary",
        "current medical history and medication list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note when treatment volume, the child's pre-cooperative age, extensive behavioral needs, medical complexity, or a special health care need makes chairside tell-show-do and nitrous inadequate for safe, complete care.\n\nWhy: Not every uncooperative child needs GA — this protocol is for the subset where in-office behavior guidance genuinely will not get treatment done safely.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify that in-office minimal sedation is not sufficient",
          "why": "Not every uncooperative child needs GA — this protocol is for the subset where in-office behavior guidance genuinely will not get treatment done safely."
        },
        {
          "detail": "Decide between an office-based moderate sedation provider and a hospital or surgery-center general anesthesia setting.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-moderate",
              "label": "Moderate sedation appropriate for the case — refer to a qualified moderate-sedation provider"
            },
            {
              "goto": "s3",
              "id": "opt-ga",
              "label": "Extent of treatment or medical complexity requires general anesthesia — refer to hospital/surgery-center GA"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "title": "Choose the referral modality"
        },
        {
          "detail": "Assemble the treatment plan, current radiographs, medical history and medication list, and the specific reason sedation/GA is being requested.\n\nWhy: The receiving provider needs the full clinical picture to plan the anesthetic safely, not just a list of teeth to treat.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "referral form",
            "treatment plan summary",
            "current medical history and medication list"
          ],
          "role": "dentist",
          "title": "Prepare the referral packet",
          "why": "The receiving provider needs the full clinical picture to plan the anesthetic safely, not just a list of teeth to treat."
        },
        {
          "detail": "Explain in plain language why in-office behavior guidance is not the recommended path for this child, what moderate sedation or GA involves at a high level, and that the receiving provider will obtain their own separate consent.\n\nWhy: The caregiver is choosing a different care pathway, not just accepting a next appointment.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the referral to the caregiver",
          "why": "The caregiver is choosing a different care pathway, not just accepting a next appointment."
        },
        {
          "detail": "The treating dentist reviews and signs the referral packet (treatment plan, radiographs, medical history, stated rationale) before it is transmitted to the sedation/GA provider — front-desk staff do not send a referral packet the dentist has not personally approved.\n\nWhy: The referral is a clinical recommendation for anesthesia in a minor; it stays a licensed, named decision even though front-desk staff carry out the sending.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Referring dentist signs off on the referral packet before it is sent.",
            "role": "referring dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Referring dentist signs off on the referral packet before it is sent",
          "why": "The referral is a clinical recommendation for anesthesia in a minor; it stays a licensed, named decision even though front-desk staff carry out the sending."
        },
        {
          "detail": "Transmit the packet to the receiving specialist or facility and confirm receipt.\n\nRecord: referral sent, packet contents, date, receiving provider",
          "id": "s6",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Send the referral to the sedation/GA provider"
        },
        {
          "detail": "Follow up with the caregiver within a set window to confirm the referral appointment was made; re-contact the receiving office if not.\n\nWhy: A sent referral that never turns into a scheduled visit leaves the child's treatment need unresolved.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the caregiver has a scheduled appointment",
          "why": "A sent referral that never turns into a scheduled visit leaves the child's treatment need unresolved."
        },
        {
          "detail": "Once sedation/GA treatment is complete, schedule the child's return to routine recall care and update the chart with what was done.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Coordinate the child's return to routine care after the procedure"
        },
        {
          "detail": "Chart the referral decision and rationale, packet sent, confirmed appointment, and the outcome once treatment under sedation/GA is complete.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the referral outcome"
        },
        {
          "detail": "Referral cycle complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Referral cycle complete"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Referral for moderate sedation or general anesthesia — Extensive treatment needs in a pre-cooperative or special-needs child.",
      "title": "Referral for moderate sedation or general anesthesia",
      "trigger": "Extensive treatment needs in a pre-cooperative or special-needs child",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for pre-visit planning intake and desensitization scheduling — no institute program reproduced",
          "source": "Generic functional equivalent for pre-visit planning intake and desensitization scheduling — no institute program reproduced"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "peds-012",
      "kind": "clinical",
      "materials": [
        "pre-visit questionnaire",
        "social story / visual schedule handout",
        "sensory accommodation kit (weighted blanket, noise-reducing headphones, sunglasses)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "When a caregiver mentions a diagnosis, sensory sensitivity, communication difference, or prior difficult dental experience, flag the chart and route to pre-visit planning instead of a standard appointment slot.\n\nWhy: Discovering special needs at check-in, rather than at scheduling, leaves no time to prepare the room, staff, or appointment length.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the patient's needs at scheduling",
          "why": "Discovering special needs at check-in, rather than at scheduling, leaves no time to prepare the room, staff, or appointment length."
        },
        {
          "detail": "Ask about diagnosis (only what the caregiver chooses to share), sensory triggers, communication style, favorite calming strategies, mobility needs, and what has helped or hurt at past medical/dental visits.\n\nWhy: Caregivers are the expert on what will work for their child; asking in advance beats guessing in the operatory.\n\nRecord: questionnaire responses in chart",
          "id": "s2",
          "kind": "step",
          "materials": [
            "pre-visit questionnaire"
          ],
          "role": "front-desk",
          "title": "Send a pre-visit questionnaire to the caregiver",
          "why": "Caregivers are the expert on what will work for their child; asking in advance beats guessing in the operatory."
        },
        {
          "detail": "Decide on appointment length, time of day, lighting/sound adjustments, sensory kit items to have ready, and whether a tell-show-do walkthrough or a separate desensitization visit is needed before any treatment is attempted.\n\nWhy: Planning accommodations ahead of time turns a chaotic visit into a predictable one for the child.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Build the visit accommodation plan",
          "why": "Planning accommodations ahead of time turns a chaotic visit into a predictable one for the child."
        },
        {
          "detail": "Decide whether a desensitization visit is needed first",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "opt-desens-needed",
              "label": "Child has no dental exposure history or strong aversion — schedule a non-treatment desensitization visit first"
            },
            {
              "goto": "s6",
              "id": "opt-direct",
              "label": "Child has tolerated care before — proceed directly to the planned visit with accommodations"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "title": "Decide whether a desensitization visit is needed first"
        },
        {
          "detail": "Have the child tour the operatory, meet the team, touch/hear equipment at low intensity, and practice sitting in the chair — no treatment attempted.\n\nWhy: A positive, treatment-free first exposure builds tolerance for the visit where actual care happens.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "social story / visual schedule handout"
          ],
          "role": "assistant",
          "title": "Run a non-treatment desensitization visit",
          "why": "A positive, treatment-free first exposure builds tolerance for the visit where actual care happens."
        },
        {
          "detail": "Set up sensory accommodations, adjust lighting/sound, brief the team on the child's plan and communication style, and hold the first or last slot of the day if that reduces waiting-room exposure.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Prepare the room and team before the child arrives"
        },
        {
          "detail": "Use tell-show-do, voice control, and caregiver presence per the standard behavior-guidance ladder, adapted to the child's plan; escalate only per that protocol's criteria.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Apply the behavior-guidance ladder with the individualized plan"
        },
        {
          "detail": "Ask the caregiver what worked and what did not, and update the chart's accommodation plan for next time.\n\nWhy: Each visit teaches the team something that makes the next visit go better.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Debrief with the caregiver after the visit",
          "why": "Each visit teaches the team something that makes the next visit go better."
        },
        {
          "detail": "Record the finalized accommodation plan, what was tried, and what worked so future visits do not start from zero.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Update the standing accommodation plan"
        },
        {
          "detail": "Visit planning cycle complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Visit planning cycle complete"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Special health care needs — pre-visit planning, desensitization, caregiver coordination — A patient with developmental, medical or sensory needs is scheduled.",
      "title": "Special health care needs — pre-visit planning, desensitization, caregiver coordination",
      "trigger": "A patient with developmental, medical or sensory needs is scheduled",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for adolescent screening checklist — no institute program reproduced",
          "source": "Generic functional equivalent for adolescent screening checklist — no institute program reproduced"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "annual",
      "id": "peds-013",
      "kind": "clinical",
      "materials": [
        "panoramic radiograph",
        "tobacco/vaping screening questions",
        "referral list for oral surgery and orthodontics"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Complete the routine hygiene recall exam and note developmental stage and any orthodontic concerns raised by the patient or caregiver.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Perform the standard adolescent recall exam"
        },
        {
          "detail": "When a panoramic radiograph is clinically indicated at this age, evaluate third-molar position, angulation, and eruption path.\n\nWhy: Early teens is the window where third-molar trajectory becomes visible and evaluable, well before extraction decisions are typically made.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "panoramic radiograph"
          ],
          "role": "dentist",
          "title": "Review third-molar development on radiographs",
          "why": "Early teens is the window where third-molar trajectory becomes visible and evaluable, well before extraction decisions are typically made."
        },
        {
          "detail": "Look for crowding, crossbite, significant overjet/overbite, or space-maintenance issues that suggest an orthodontic evaluation is timely.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "opt-refer-ortho",
              "label": "Findings suggest orthodontic evaluation would be timely — refer"
            },
            {
              "goto": "s5",
              "id": "opt-no-referral",
              "label": "No orthodontic concern at this visit — continue routine monitoring"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "title": "Assess orthodontic timing"
        },
        {
          "detail": "Send a referral with the relevant radiographs and clinical notes to an orthodontist and, if third-molar findings warrant it, an oral surgeon.\n\nWhy: Unlike the sedation/GA referral protocol (which gates the packet before sending because front-desk staff carry out that send and the referral is a recommendation for anesthesia in a minor), this referral is decided and sent by the treating dentist in the same visit, and carries no anesthesia risk — so no separate licensed-signoff gate is added here.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "referral list for oral surgery and orthodontics"
          ],
          "role": "dentist",
          "title": "Refer for orthodontic and/or oral surgery consultation as indicated",
          "why": "Unlike the sedation/GA referral protocol (which gates the packet before sending because front-desk staff carry out that send and the referral is a recommendation for anesthesia in a minor), this referral is decided and sent by the treating dentist in the same visit, and carries no anesthesia risk — so no separate licensed-signoff gate is added here."
        },
        {
          "detail": "Ask age-appropriate, non-judgmental screening questions about cigarette, smokeless tobacco, and vaping/e-cigarette use, with the caregiver stepping out if that improves candor.\n\nWhy: Adolescence is the typical age of first tobacco/nicotine exposure, and oral tissue changes can be an early clinical signal.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "tobacco/vaping screening questions"
          ],
          "role": "dentist",
          "title": "Screen for tobacco and vaping use",
          "why": "Adolescence is the typical age of first tobacco/nicotine exposure, and oral tissue changes can be an early clinical signal."
        },
        {
          "detail": "Respond to the screen result",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "opt-negative",
              "label": "Negative screen — reinforce prevention message and continue"
            },
            {
              "goto": "s9",
              "id": "opt-positive",
              "label": "Positive screen — offer brief counseling and cessation resources"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "title": "Respond to the screen result"
        },
        {
          "detail": "Chart third-molar assessment, orthodontic referral decision, and tobacco/vaping screen result and any counseling given.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the transition-visit findings"
        },
        {
          "detail": "Adolescent transition visit complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Adolescent transition visit complete"
        },
        {
          "detail": "Provide a short, non-judgmental counseling conversation and hand out cessation resource information appropriate to the patient's age.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Offer brief counseling and cessation resources"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Adolescent transition — third-molar evaluation, orthodontic timing, tobacco and vaping screen — A patient reaches the early teens at a recall.",
      "title": "Adolescent transition — third-molar evaluation, orthodontic timing, tobacco and vaping screen",
      "trigger": "A patient reaches the early teens at a recall",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6.2 (in-repo pediatric restorative basis, applied generically)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6.2 (in-repo pediatric restorative basis, applied generically)"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "peds-014",
      "kind": "clinical",
      "materials": [
        "desensitizing agent (e.g. fluoride varnish, CPP-ACP paste)",
        "intraoral photographs",
        "restorative materials as indicated (glass ionomer, composite, or stainless steel crown (SSC) per severity)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Examine first permanent molars and incisors for demarcated opacities (white/cream/yellow/brown), post-eruptive enamel breakdown, and atypical restorations; photograph with consent.\n\nWhy: MIH has a distinctive demarcated-opacity pattern that distinguishes it from ordinary decalcification or fluorosis, which changes the management approach.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "intraoral photographs"
          ],
          "role": "dentist",
          "title": "Identify and document the affected teeth",
          "why": "MIH has a distinctive demarcated-opacity pattern that distinguishes it from ordinary decalcification or fluorosis, which changes the management approach."
        },
        {
          "detail": "Classify each affected tooth as mild (opacity only, no breakdown), moderate (limited breakdown, some sensitivity), or severe (extensive breakdown, marked sensitivity, or a molar too compromised to restore conservatively).\n\nRecord: severity grade per tooth in chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Grade severity per affected tooth"
        },
        {
          "detail": "Apply a desensitizing agent and counsel on a soft-bristle brush and lukewarm rinsing; give the child and caregiver time to see if sensitivity improves before deciding on restorative treatment.\n\nWhy: MIH teeth are often painfully sensitive, which affects the child's ability to tolerate exam and treatment — controlling sensitivity first improves both comfort and diagnostic accuracy.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "desensitizing agent (e.g. fluoride varnish, CPP-ACP paste)"
          ],
          "role": "hygienist",
          "title": "Address hypersensitivity before restorative decisions",
          "why": "MIH teeth are often painfully sensitive, which affects the child's ability to tolerate exam and treatment — controlling sensitivity first improves both comfort and diagnostic accuracy."
        },
        {
          "detail": "The treating dentist confirms the severity grade and chosen restoration strategy (monitor, direct restoration, or full-coverage/extraction) before it is scheduled — a hygienist's severity note is input, not the deciding call.\n\nWhy: Choosing between monitoring, a direct restoration, and full-coverage or extraction on a hypomineralized permanent molar is a consequential, hard-to-reverse clinical decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed dentist signs off on the restoration strategy.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed dentist signs off on the restoration strategy",
          "why": "Choosing between monitoring, a direct restoration, and full-coverage or extraction on a hypomineralized permanent molar is a consequential, hard-to-reverse clinical decision."
        },
        {
          "detail": "Match the strategy to the severity grade already recorded at step-grade-severity — this is a classification lookup, not a preference choice.\n\nWhy: 'advised' on the mild/monitor branch marks only the default rendering order for this decision node; it is not a clinical recommendation to prefer monitoring over restoring — the severity grade already documented drives which branch is correct for a given tooth.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "opt-mild",
              "label": "Mild — monitor and reinforce prevention, no restoration yet"
            },
            {
              "goto": "s10",
              "id": "opt-moderate",
              "label": "Moderate — direct restoration (glass ionomer or composite) of the affected surface"
            },
            {
              "goto": "s11",
              "id": "opt-severe",
              "label": "Severe — full-coverage restoration (e.g. stainless steel crown) or extraction/space-maintenance planning for a badly compromised molar"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "title": "Choose the restoration strategy by severity",
          "why": "'advised' on the mild/monitor branch marks only the default rendering order for this decision node; it is not a clinical recommendation to prefer monitoring over restoring — the severity grade already documented drives which branch is correct for a given tooth."
        },
        {
          "detail": "Reassess opacities at each recall for progression to breakdown and reinforce fluoride and diet counseling.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Monitor mild cases at each recall"
        },
        {
          "detail": "Explain that MIH is a developmental enamel condition present from tooth formation, not caused by poor hygiene, and walk through the chosen management plan and expected follow-up.\n\nWhy: Caregivers often assume chalky spots mean decay from poor brushing; correcting that avoids unwarranted guilt and sets expectations for closer monitoring.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the condition and plan to the caregiver",
          "why": "Caregivers often assume chalky spots mean decay from poor brushing; correcting that avoids unwarranted guilt and sets expectations for closer monitoring."
        },
        {
          "detail": "Chart affected teeth, severity grading, desensitizing steps taken, restoration chosen (if any), and the caregiver counseling given.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the MIH management plan"
        },
        {
          "detail": "MIH management visit complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "MIH management visit complete"
        },
        {
          "detail": "Remove affected, poorly bonding enamel and restore with a material suited to the defective substrate; because MIH enamel bonds unpredictably, expect closer recall for restoration integrity.\n\nWhy: Hypomineralized enamel bonds less reliably than normal enamel, which is why restorations on these teeth need closer follow-up regardless of material chosen.",
          "id": "s10",
          "kind": "step",
          "materials": [
            "restorative materials as indicated (glass ionomer, composite, or stainless steel crown (SSC) per severity)"
          ],
          "role": "dentist",
          "title": "Restore moderate breakdown directly",
          "why": "Hypomineralized enamel bonds less reliably than normal enamel, which is why restorations on these teeth need closer follow-up regardless of material chosen."
        },
        {
          "detail": "For a molar with extensive breakdown, place a full-coverage restoration to protect the remaining tooth structure; if the tooth is not restorable, coordinate extraction and space-maintenance planning with the extraction/space-maintenance decision protocol.",
          "id": "s11",
          "kind": "step",
          "materials": [
            "restorative materials as indicated (glass ionomer, composite, or stainless steel crown (SSC) per severity)"
          ],
          "role": "dentist",
          "title": "Plan full-coverage restoration or extraction for severe cases"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Molar-incisor hypomineralization — sensitivity control and restoration strategy — A child with chalky, sensitive first molars.",
      "title": "Molar-incisor hypomineralization — sensitivity control and restoration strategy",
      "trigger": "A child with chalky, sensitive first molars",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "source": "AAPD Oral Health Policies and Clinical Recommendations (openly published)",
          "url": "https://www.aapd.org/research/oral-health-policies--recommendations/"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for frenulum assessment checklist — no proprietary scoring tool reproduced",
          "source": "Generic functional equivalent for frenulum assessment checklist — no proprietary scoring tool reproduced"
        }
      ],
      "class": "pediatric-behavior-guidance",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "peds-015",
      "kind": "clinical",
      "materials": [
        "frenulum assessment tool/checklist",
        "topical anesthetic",
        "sterile scissors or laser device per office capability",
        "gauze"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask about latch difficulty, nipple pain, poor weight gain, prolonged feeds, clicking sounds, or a lactation consultant's referral note.\n\nWhy: The presenting problem is a feeding problem, not a dental complaint — the exam only matters in that context.\n\nRecord: feeding history and referral source in chart",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Take a feeding history from the caregiver",
          "why": "The presenting problem is a feeding problem, not a dental complaint — the exam only matters in that context."
        },
        {
          "detail": "Examine the lingual and/or labial frenulum's attachment point, tissue elasticity, and the infant's tongue range of motion (lift, lateralization, extension), using a consistent checklist rather than a quick visual glance.\n\nWhy: A brief visual look overcalls or undercalls tie severity; a structured functional assessment is what actually predicts feeding impact.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "frenulum assessment tool/checklist"
          ],
          "role": "dentist",
          "title": "Perform a structured frenulum assessment",
          "why": "A brief visual look overcalls or undercalls tie severity; a structured functional assessment is what actually predicts feeding impact."
        },
        {
          "detail": "Correlate the anatomical finding with the actual feeding difficulty reported, not anatomy alone.\n\nWhy: 'advised' on the not-significant branch marks only the default rendering order for this decision node, not a clinical preference for withholding a frenotomy — the correct branch is whatever the correlated exam and feeding-history findings actually show.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "opt-not-significant",
              "label": "Anatomy present but function and feeding are adequate — no procedure, support feeding another way"
            },
            {
              "goto": "s7",
              "id": "opt-significant",
              "label": "Restricted function correlating with real feeding difficulty — frenotomy is a reasonable option"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "title": "Decide whether the tie is functionally significant",
          "why": "'advised' on the not-significant branch marks only the default rendering order for this decision node, not a clinical preference for withholding a frenotomy — the correct branch is whatever the correlated exam and feeding-history findings actually show."
        },
        {
          "detail": "Coordinate with the lactation consultant on positioning and latch technique, and schedule a re-check if feeding does not improve.\n\nWhy: Not every visible tie needs cutting; overcalling frenotomy exposes an infant to an unnecessary procedure.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Offer conservative support instead of a procedure",
          "why": "Not every visible tie needs cutting; overcalling frenotomy exposes an infant to an unnecessary procedure."
        },
        {
          "detail": "Chart the structured assessment findings, functional-significance decision, consent (if a procedure was performed), procedure details, and follow-up plan.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the assessment and outcome"
        },
        {
          "detail": "Tongue-tie/lip-tie visit complete",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Tongue-tie/lip-tie visit complete"
        },
        {
          "detail": "Explain the procedure, expected benefit, risks (bleeding, recurrence, rare injury to surrounding structures), and the option of watchful waiting; caregiver signs before the procedure is performed.\n\nWhy: This is a procedure on a newborn/infant based on a functional judgment call — documented informed consent is the safeguard against acting on anatomy alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain written informed consent before any frenotomy.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "caregiver",
          "title": "Obtain written informed consent before any frenotomy",
          "why": "This is a procedure on a newborn/infant based on a functional judgment call — documented informed consent is the safeguard against acting on anatomy alone."
        },
        {
          "detail": "Apply topical anesthetic, stabilize the infant per office protocol, and release the frenulum using sterile scissors or a laser device per the office's equipment and training; control bleeding with gauze pressure.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "topical anesthetic",
            "sterile scissors or laser device per office capability",
            "gauze"
          ],
          "role": "dentist",
          "title": "Perform the frenotomy"
        },
        {
          "detail": "Encourage breast or bottle feeding right after the procedure to assess immediate latch/suck improvement and to comfort the infant.\n\nWhy: Immediate feeding both soothes the infant and gives the caregiver and provider a first read on whether function improved.",
          "id": "s9",
          "kind": "step",
          "role": "caregiver",
          "title": "Have the caregiver feed the infant immediately after",
          "why": "Immediate feeding both soothes the infant and gives the caregiver and provider a first read on whether function improved."
        },
        {
          "detail": "Explain wound-site care, expected healing appearance, and any recommended gentle stretching exercises to reduce reattachment, plus warning signs to call about.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Give aftercare and stretching instructions"
        },
        {
          "detail": "Book a follow-up with the caregiver and, when involved, the lactation consultant to reassess feeding and healing.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Schedule a feeding follow-up"
        }
      ],
      "subclass": "pediatric-dentistry-and-behavior-guidance",
      "summary": "Infant tongue-tie or lip-tie assessment and frenotomy decision — A lactation consultant or parent asks about a tethered oral tissue in an infant with feeding difficulty.",
      "title": "Infant tongue-tie or lip-tie assessment and frenotomy decision",
      "trigger": "A lactation consultant or parent asks about a tethered oral tissue in an infant with feeding difficulty",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal examination basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal examination basis)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "perio-001",
      "kind": "clinical",
      "materials": [
        "periodontal probe (UNC-15 or similar)",
        "full-mouth or bitewing radiographs",
        "existing chart history",
        "periodontal charting form or module"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Probe mesiobuccal, mid-buccal, distobuccal, mesiolingual, mid-lingual and distolingual on every tooth present.\n\nWhy: Six-point probing is the AAP-referenced standard depth for detecting localized attachment loss that fewer points can miss.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Probe six points per tooth",
          "why": "Six-point probing is the AAP-referenced standard depth for detecting localized attachment loss that fewer points can miss."
        },
        {
          "detail": "Record probing depths, bleeding on probing, recession, furcation involvement, mobility and suppuration for each tooth.\n\nRecord: periodontal chart entries in the patient record",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Record the full set of periodontal findings"
        },
        {
          "detail": "Compare current radiographs to prior films and note the percent and pattern of radiographic bone loss relative to root length.\n\nWhy: Radiographic bone loss is the critical data point the AAP staging system uses to separate Stage I/II from Stage III/IV.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review radiographic bone loss",
          "why": "Radiographic bone loss is the critical data point the AAP staging system uses to separate Stage I/II from Stage III/IV."
        },
        {
          "detail": "Using interdental clinical attachment loss, radiographic bone loss and tooth loss for stage, and rate of progression plus risk factors for grade, assign the formal diagnosis.\n\nWhy: Staging and grading together set the treatment plan and the review interval, not clinical judgment alone.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Assign AAP 2018 staging (I-IV) and grading (A/B/C)",
          "why": "Staging and grading together set the treatment plan and the review interval, not clinical judgment alone."
        },
        {
          "detail": "The treating dentist reviews and signs off on the staging/grading before it drives any treatment plan or billing code.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the periodontal diagnosis before it enters the treatment plan.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the periodontal diagnosis before it enters the treatment plan"
        },
        {
          "detail": "Enter the finalized stage/grade and next-step recommendation (SRP, re-evaluation interval, or referral) into the chart note.\n\nRecord: diagnosis, stage, grade and planned pathway in the clinical note",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document the final diagnosis and plan pathway"
        },
        {
          "detail": "Diagnosis complete and charted",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Diagnosis complete and charted"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Periodontal diagnosis with staging and grading — A full chart and radiographs show attachment or bone loss and a formal diagnosis is required.",
      "title": "Periodontal diagnosis with staging and grading",
      "trigger": "A full chart and radiographs show attachment or bone loss and a formal diagnosis is required",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during SRP)",
          "source": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during SRP)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (in-repo SRP basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (in-repo SRP basis)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-patient",
      "id": "perio-002",
      "kind": "clinical",
      "materials": [
        "local anesthetic (block or infiltration per quadrant)",
        "ultrasonic scaler with appropriate tip",
        "hand curets (Gracey series)",
        "high-volume evacuation / aerosol control",
        "personal protective equipment per bloodborne pathogen standard"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify which quadrant is scheduled today, review the medical history and allergy list, and confirm informed consent for anesthesia is on file.\n\nWhy: SRP is typically staged two quadrants per visit, so confirming the correct quadrant and any medical contraindication prevents a mismatched or unsafe appointment.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm the SRP quadrant plan and medical history",
          "why": "SRP is typically staged two quadrants per visit, so confirming the correct quadrant and any medical contraindication prevents a mismatched or unsafe appointment."
        },
        {
          "detail": "Confirm the patient has given informed consent for local anesthesia and the SRP procedure before any injection is given.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent for local anesthesia and the procedure.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "hygienist",
          "title": "Confirm consent for local anesthesia and the procedure"
        },
        {
          "detail": "Administer a block or infiltration technique appropriate to the quadrant being treated and confirm profound anesthesia before instrumentation.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia appropriate to the quadrant"
        },
        {
          "detail": "Use the ultrasonic scaler first to remove gross calculus and disrupt subgingival biofilm across the quadrant.\n\nWhy: Ultrasonic-first instrumentation clears gross deposits efficiently and disrupts biofilm before finer hand instrumentation.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Remove gross calculus with ultrasonic instrumentation",
          "why": "Ultrasonic-first instrumentation clears gross deposits efficiently and disrupts biofilm before finer hand instrumentation."
        },
        {
          "detail": "Use Gracey series curets for root surface debridement, working apex to coronal with overlapping vertical, oblique and horizontal strokes.\n\nWhy: Hand instrumentation reaches root surface texture that ultrasonic tips alone can miss, and the apex-to-coronal stroke pattern is the referenced technique for thorough root planing.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Hand scale root surfaces with Gracey curets",
          "why": "Hand instrumentation reaches root surface texture that ultrasonic tips alone can miss, and the apex-to-coronal stroke pattern is the referenced technique for thorough root planing."
        },
        {
          "detail": "Confirm high-volume evacuation is running, PPE (mask, eyewear, gloves, gown) is worn, and sharps are handled per the bloodborne pathogen standard throughout instrumentation.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm aerosol and bloodborne exposure controls are in place"
        },
        {
          "detail": "Advise on expected soreness, sensitivity, home care adjustments, and any prescribed rinse, and confirm the patient's understanding before dismissal.",
          "id": "s7",
          "kind": "step",
          "role": "hygienist",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Document the quadrant treated, instruments used, and anesthetic type and amount in the clinical note.\n\nRecord: quadrant treated, instruments used, anesthetic in the clinical note",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Document quadrant, instruments and anesthetic used"
        },
        {
          "detail": "Is another quadrant still pending, or is this the last one?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "another-quadrant",
              "label": "Schedule the next quadrant appointment"
            },
            {
              "goto": "s12",
              "id": "last-quadrant",
              "label": "This was the final quadrant — route to re-evaluation scheduling"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is another quadrant still pending, or is this the last one?"
        },
        {
          "detail": "Front desk schedules the next quadrant's SRP appointment per the treatment plan sequence.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to scheduling for the next quadrant"
        },
        {
          "detail": "Quadrant SRP visit complete",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Quadrant SRP visit complete"
        },
        {
          "detail": "Route the completed case to the periodontal re-evaluation protocol (perio-004) to be scheduled 4-6 weeks out.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the re-evaluation protocol"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Scaling and root planing by quadrant with anesthesia — Periodontitis is diagnosed and non-surgical therapy is planned.",
      "title": "Scaling and root planing by quadrant with anesthesia",
      "trigger": "Periodontitis is diagnosed and non-surgical therapy is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (in-repo SRP basis, adjunct decision extended generically)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (in-repo SRP basis, adjunct decision extended generically)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "perio-003",
      "kind": "clinical",
      "materials": [
        "locally delivered antimicrobial (site-specific)",
        "systemic antibiotic prescription pad or e-prescribing",
        "host-modulation agent (if used)",
        "current periodontal chart and medical/allergy history"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify each site at 5 mm or greater with bleeding on probing that remains after initial SRP, or a case flagged as rapidly progressing.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Identify residual pockets and their bleeding status"
        },
        {
          "detail": "Check for antibiotic allergies, pregnancy status, anticoagulant use and any drug interaction relevant to the adjunct being considered.\n\nWhy: A locally delivered antimicrobial or systemic antibiotic decision must not proceed without confirming it is safe for this specific patient.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Check medical history, allergies and current medications",
          "why": "A locally delivered antimicrobial or systemic antibiotic decision must not proceed without confirming it is safe for this specific patient."
        },
        {
          "detail": "The treating dentist confirms the adjunct choice, dose and site before any locally delivered agent, systemic antibiotic or host-modulation agent is placed or prescribed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before any adjunct is placed or prescribed.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before any adjunct is placed or prescribed"
        },
        {
          "detail": "Which adjunct, if any, is indicated?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "locally-delivered",
              "label": "Site-specific locally delivered antimicrobial into the residual pocket"
            },
            {
              "goto": "s9",
              "id": "systemic-antibiotic",
              "label": "Systemic antibiotic for a generalized aggressive or rapidly progressing case"
            },
            {
              "goto": "s10",
              "id": "host-modulation",
              "label": "Host-modulation agent as an adjunct to reduce collagenase activity"
            },
            {
              "goto": "s6",
              "id": "none",
              "label": "No adjunct indicated — monitor at re-evaluation"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Which adjunct, if any, is indicated?"
        },
        {
          "detail": "Place the locally delivered antimicrobial directly into the identified residual pocket per the product's placement technique.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Place the locally delivered antimicrobial at the site"
        },
        {
          "detail": "Document which adjunct was used or that none was indicated, the sites treated, and the rationale in the chart note.\n\nRecord: adjunct chosen, sites treated, rationale in the clinical note",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document the adjunct decision and rationale"
        },
        {
          "detail": "Route the patient to scheduling for a re-evaluation appointment consistent with the periodontal re-evaluation protocol (perio-004).",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to schedule the re-evaluation"
        },
        {
          "detail": "Adjunct decision complete and charted",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Adjunct decision complete and charted"
        },
        {
          "detail": "Prescribe the systemic antibiotic and dosing appropriate to the diagnosis and confirmed history, following the dentist's clinical judgment and current prescribing guidance.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe the systemic antibiotic course"
        },
        {
          "detail": "Prescribe or place the host-modulation agent per its indicated regimen as an adjunct to mechanical therapy.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe or place the host-modulation agent"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Adjunct selection — locally delivered antimicrobial, systemic antibiotic or host modulation — Residual pockets of 5 mm or more with bleeding after initial SRP, or a rapidly progressing case.",
      "title": "Adjunct selection — locally delivered antimicrobial, systemic antibiotic or host modulation",
      "trigger": "Residual pockets of 5 mm or more with bleeding after initial SRP, or a rapidly progressing case",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (re-evaluation 4-6 weeks post-SRP)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (re-evaluation 4-6 weeks post-SRP)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "perio-004",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "prior SRP chart entries for comparison",
        "current radiographs if indicated"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm at least 4-6 weeks have passed since the final SRP quadrant was completed before re-probing.\n\nWhy: Re-probing too early can show inflammation that has not fully resolved and produce a falsely pessimistic reading.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Confirm the healing window has passed",
          "why": "Re-probing too early can show inflammation that has not fully resolved and produce a falsely pessimistic reading."
        },
        {
          "detail": "Re-probe pocket depths, bleeding on probing, recession and mobility at all sites treated during SRP and compare to the pre-SRP baseline.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Re-probe all previously treated sites"
        },
        {
          "detail": "Compare current pocket depths and bleeding to the pre-SRP chart to identify sites that responded and sites that did not.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Compare current findings to the pre-SRP baseline"
        },
        {
          "detail": "The treating dentist confirms the comparison to baseline before the case is routed to maintenance, an adjunct, or a surgical referral.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the re-evaluation finding before the pathway is set.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the re-evaluation finding before the pathway is set"
        },
        {
          "detail": "How did the periodontium respond to non-surgical therapy?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "responded",
              "label": "Sites responded — place on periodontal maintenance"
            },
            {
              "goto": "s9",
              "id": "non-responding",
              "label": "Non-responding sites remain, furcation or mucogingival concerns present"
            },
            {
              "goto": "s10",
              "id": "adjunct-candidate",
              "label": "Localized non-response that may respond to an adjunct rather than surgery"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "How did the periodontium respond to non-surgical therapy?"
        },
        {
          "detail": "Set the periodontal maintenance recall interval (typically 3-4 months) and document the maintenance plan.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Place the patient on periodontal maintenance"
        },
        {
          "detail": "Document the comparison to baseline, the response decision, and the chosen next pathway in the chart note.\n\nRecord: re-evaluation findings and next pathway in the clinical note",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the re-evaluation findings and pathway"
        },
        {
          "detail": "Re-evaluation complete and pathway set",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Re-evaluation complete and pathway set"
        },
        {
          "detail": "Hand the non-responding sites and findings to the surgical periodontal referral decision protocol (perio-005).",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the surgical periodontal referral protocol"
        },
        {
          "detail": "Hand the localized non-responding sites to the SRP adjunct selection protocol (perio-003) before considering surgical referral.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the adjunct selection protocol"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Periodontal re-evaluation 4-6 weeks after SRP — All planned SRP quadrants are complete and the healing window has passed.",
      "title": "Periodontal re-evaluation 4-6 weeks after SRP",
      "trigger": "All planned SRP quadrants are complete and the healing window has passed",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (referral threshold extended generically from re-evaluation guidance)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.2 (referral threshold extended generically from re-evaluation guidance)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "perio-005",
      "kind": "clinical",
      "materials": [
        "current periodontal chart and radiographs",
        "referral letter template",
        "list of periodontal specialists the practice refers to"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "specialist-referral",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Review residual pocket depth, furcation involvement, mucogingival deficiency, and candidacy for regenerative therapy against the practice's in-house treatment threshold.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review the findings against referral criteria"
        },
        {
          "detail": "Does this case meet the surgical referral threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "refer",
              "label": "Meets threshold — refer to a periodontal specialist"
            },
            {
              "goto": "s8",
              "id": "in-house",
              "label": "Within the practice's in-house surgical scope"
            },
            {
              "goto": "s9",
              "id": "continue-monitoring",
              "label": "Does not yet meet threshold — continue non-surgical monitoring"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does this case meet the surgical referral threshold?"
        },
        {
          "detail": "Prepare a referral letter summarizing the diagnosis, staging/grading, non-surgical treatment already completed, and the specific reason for referral (e.g. furcation, mucogingival deficiency, regenerative candidacy), with chart and radiographs attached.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the referral packet"
        },
        {
          "detail": "Confirm the patient has consented to the practice sharing chart notes and radiographs with the receiving specialist office before transmission.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient consent to share records with the specialist.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "front-desk",
          "title": "Confirm patient consent to share records with the specialist"
        },
        {
          "detail": "Front desk transmits the referral packet to the selected periodontal specialist and schedules the patient's follow-up call.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the referral to the specialist"
        },
        {
          "detail": "Document the referral sent (or in-house routing chosen), the reason, and the date in the chart.\n\nRecord: referral sent, reason and date in the patient record",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the referral or in-house routing decision"
        },
        {
          "detail": "Referral decision complete and documented",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Referral decision complete and documented"
        },
        {
          "detail": "If within the treating dentist's scope and the practice's declared in-house capability, route the case to the matching in-house surgical protocol.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the appropriate in-house surgical protocol"
        },
        {
          "detail": "Document the finding, why referral was not indicated at this time, and the next monitoring interval.\n\nRecord: monitoring decision and rationale in the clinical note",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the decision to continue monitoring"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Surgical periodontal referral decision (pocket depth, furcation, mucogingival, regenerative) — Re-evaluation shows non-responding sites, furcation involvement or a mucogingival deficiency beyond the practice's in-house threshold.",
      "title": "Surgical periodontal referral decision (pocket depth, furcation, mucogingival, regenerative)",
      "trigger": "Re-evaluation shows non-responding sites, furcation involvement or a mucogingival deficiency beyond the practice's in-house threshold",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification (periodontal abscess as a periodontal condition)",
          "source": "AAP 2017 classification (periodontal abscess as a periodontal condition)",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5 (periodontal protocols section, abscess management extended generically)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5 (periodontal protocols section, abscess management extended generically)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "perio-006",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "periodontal probe",
        "irrigation syringe and antimicrobial irrigant",
        "drainage/incision instruments if indicated"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Call 911 or direct the patient to the nearest emergency department immediately if there is fever, facial swelling, difficulty swallowing or breathing, or rapidly spreading swelling; do not attempt in-office drainage in that case. If none of these signs are present, continue to confirm the infection is localized to the periodontal pocket.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Screen for a spreading or systemic infection before any localized treatment.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Screen for a spreading or systemic infection before any localized treatment"
        },
        {
          "detail": "Confirm: is this a localized periodontal abscess with no spreading or systemic signs?",
          "forks": [
            {
              "goto": "s9",
              "id": "spreading",
              "label": "Spreading or systemic signs are present — the emergency instructions above apply; stop here"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "localized",
              "label": "Confirmed localized to the periodontal pocket"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm: is this a localized periodontal abscess with no spreading or systemic signs?"
        },
        {
          "detail": "Examine the localized swelling, probe the associated pocket, and confirm suppuration and pocket depth.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Examine and probe the affected site"
        },
        {
          "detail": "Confirm informed consent for local anesthesia and the drainage procedure before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent before anesthesia and drainage.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent before anesthesia and drainage"
        },
        {
          "detail": "Administer local anesthesia, achieve drainage through the pocket or a small incision as indicated, and irrigate the site with an antimicrobial irrigant.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Anesthetize and drain the abscess"
        },
        {
          "detail": "Is a systemic antibiotic indicated in addition to drainage?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "drainage-only",
              "label": "Drainage alone is sufficient"
            },
            {
              "goto": "s10",
              "id": "add-antibiotic",
              "label": "Add a systemic antibiotic (fever, cellulitis, immunocompromise, or inadequate drainage)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a systemic antibiotic indicated in addition to drainage?"
        },
        {
          "detail": "Advise on warm saline rinses, signs that require a return call, and schedule a follow-up visit within about one week for SRP or re-evaluation of the site.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-drainage instructions and schedule follow-up"
        },
        {
          "detail": "Document the presenting findings, drainage performed, any antibiotic prescribed, and the follow-up plan in the chart note.\n\nRecord: presentation, treatment and follow-up plan in the clinical note",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the presentation, treatment and follow-up plan"
        },
        {
          "detail": "Abscess management complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Abscess management complete"
        },
        {
          "detail": "Prescribe a systemic antibiotic appropriate to the clinical picture and confirmed allergy history.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe the systemic antibiotic"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Periodontal abscess drainage and management — A patient presents with localized gingival swelling, suppuration and a deep pocket.",
      "title": "Periodontal abscess drainage and management",
      "trigger": "A patient presents with localized gingival swelling, suppuration and a deep pocket",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification (necrotizing periodontal diseases)",
          "source": "AAP 2017 classification (necrotizing periodontal diseases)",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5 covers periodontal exam/charting, SRP, and implant maintenance only — no necrotizing-disease content; per standard periodontal-emergency management (gentle debridement, antimicrobial rinse, systemic risk-factor screening, urgent follow-up) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md §5 covers periodontal exam/charting, SRP, and implant maintenance only — no necrotizing-disease content; generic functional equivalent per standard periodontal-emergency management (gentle debridement, antimicrobial rinse, systemic risk-factor screening, urgent follow-up)"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Direct read of DOCS/TECHNICAL_PROTOCOLS.md §5 (lines 164-189): §5.1 Periodontal Examination, §5.2 Scaling and Root Planing, §5.3 Implant Maintenance. No mention of ANUG/NUP/necrotizing disease, antimicrobial rinse, or systemic-factor workup.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §5 (periodontal protocols section, necrotizing disease management extended generically)",
              "url": null
            }
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5 covers periodontal exam/charting, SRP, and implant maintenance only — no necrotizing-disease content; per standard periodontal-emergency management (gentle debridement, antimicrobial rinse, systemic risk-factor screening, urgent follow-up) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "perio-007",
      "kind": "clinical",
      "materials": [
        "local anesthetic (topical/light infiltration as tolerated)",
        "gentle debridement instruments",
        "hydrogen peroxide or chlorhexidine rinse",
        "systemic antibiotic prescription pad if indicated"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the patient has high fever, facial swelling, difficulty swallowing or breathing, or appears acutely systemically ill, call 911 or direct the patient to the nearest emergency department immediately.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Screen for systemic involvement requiring emergency escalation.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Screen for systemic involvement requiring emergency escalation"
        },
        {
          "detail": "Confirm painful ulcerated interdental papillae with a pseudomembrane, spontaneous bleeding and characteristic fetor odoris, consistent with necrotizing gingivitis or periodontitis.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the clinical diagnosis"
        },
        {
          "detail": "Screen for smoking, extreme psychological stress, malnutrition, and any sign of immunocompromise (e.g. HIV status, uncontrolled diabetes) that may need medical referral in parallel.\n\nWhy: Necrotizing periodontal disease is strongly associated with stress, malnutrition and immunocompromise, and an underlying medical cause needs its own referral alongside dental treatment.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Screen risk history for an underlying cause",
          "why": "Necrotizing periodontal disease is strongly associated with stress, malnutrition and immunocompromise, and an underlying medical cause needs its own referral alongside dental treatment."
        },
        {
          "detail": "The treating dentist confirms the diagnosis and risk screen before any debridement, rinse prescription or antibiotic is given.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before debridement or any prescription.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before debridement or any prescription"
        },
        {
          "detail": "Confirm informed consent for local anesthesia and gentle debridement of the necrotic tissue before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent before debridement.",
            "type": "safety"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent before debridement"
        },
        {
          "detail": "Perform gentle superficial debridement of the necrotic tissue with topical or light local anesthesia, avoiding aggressive instrumentation on the acutely inflamed tissue.\n\nWhy: Aggressive instrumentation on necrotic, acutely inflamed tissue at the first visit can worsen pain and tissue damage; a gentler initial pass is the accepted first-visit approach before definitive SRP.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Perform gentle superficial debridement",
          "why": "Aggressive instrumentation on necrotic, acutely inflamed tissue at the first visit can worsen pain and tissue damage; a gentler initial pass is the accepted first-visit approach before definitive SRP."
        },
        {
          "detail": "Prescribe a chlorhexidine or diluted hydrogen peroxide rinse for home use and instruct on gentle oral hygiene until acute symptoms resolve.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe an antimicrobial rinse and give home-care instructions"
        },
        {
          "detail": "Is a systemic antibiotic indicated?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "debridement-and-rinse",
              "label": "Debridement and rinse are sufficient for a mild, localized case"
            },
            {
              "goto": "s13",
              "id": "add-systemic",
              "label": "Add a systemic antibiotic (fever, lymphadenopathy, or immunocompromise present)"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a systemic antibiotic indicated?"
        },
        {
          "detail": "Does the risk history suggest an undiagnosed medical condition needing referral?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "no-referral-needed",
              "label": "No — risk factors are known and managed"
            },
            {
              "goto": "s14",
              "id": "medical-referral",
              "label": "Yes — refer for medical evaluation in parallel with dental treatment"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the risk history suggest an undiagnosed medical condition needing referral?"
        },
        {
          "detail": "Schedule a follow-up visit within 24-48 hours to assess healing and plan definitive SRP once acute symptoms have resolved.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a 24-48 hour follow-up"
        },
        {
          "detail": "Document the diagnosis, risk history reviewed, treatment given, any antibiotic prescribed, any medical referral, and the follow-up plan.\n\nRecord: diagnosis, treatment, referral and follow-up plan in the clinical note",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the diagnosis, treatment and follow-up plan"
        },
        {
          "detail": "Necrotizing periodontal disease management complete",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Necrotizing periodontal disease management complete"
        },
        {
          "detail": "Prescribe a systemic antibiotic appropriate to the clinical picture and confirmed allergy history.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribe the systemic antibiotic"
        },
        {
          "detail": "Provide the patient with a referral to their physician for evaluation of a possible underlying immunocompromising or nutritional condition.",
          "id": "s14",
          "kind": "step",
          "role": "front-desk",
          "title": "Refer for medical evaluation"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Necrotizing gingivitis or periodontitis management — Painful ulcerated papillae, pseudomembrane and fetor in a stressed or immunocompromised patient.",
      "title": "Necrotizing gingivitis or periodontitis management",
      "trigger": "Painful ulcerated papillae, pseudomembrane and fetor in a stressed or immunocompromised patient",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification (recession and mucogingival conditions)",
          "source": "AAP 2017 classification (recession and mucogingival conditions)",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal examination basis, recession assessment extended generically)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal examination basis, recession assessment extended generically)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "perio-008",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "intraoral photographs",
        "recession/attached gingiva measurement record",
        "referral letter template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Measure the amount of recession, the width of attached (keratinized) gingiva, and any frenal pull or shallow vestibule contributing to the site.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Measure recession and attached gingiva at the affected site"
        },
        {
          "detail": "Ask the patient about root sensitivity to thermal or tactile stimuli and note any esthetic concern raised about the site.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Assess root sensitivity and esthetic concern"
        },
        {
          "detail": "Capture intraoral photographs of the recession site for the record and for any referral packet.\n\nWhy: Photographs give the receiving specialist and the patient's record a baseline to compare healing or progression against over time.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Document the site with intraoral photographs",
          "why": "Photographs give the receiving specialist and the patient's record a baseline to compare healing or progression against over time."
        },
        {
          "detail": "The treating dentist confirms the measurements and photographs before deciding between in-house management and a grafting referral.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before choosing management or referral.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before choosing management or referral"
        },
        {
          "detail": "How significant is the recession and mucogingival deficiency?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "mild-monitor",
              "label": "Mild, stable recession with adequate attached gingiva — monitor and manage sensitivity"
            },
            {
              "goto": "s9",
              "id": "grafting-candidate",
              "label": "Progressive recession, inadequate attached gingiva, or esthetic concern warranting grafting evaluation"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "How significant is the recession and mucogingival deficiency?"
        },
        {
          "detail": "Apply or recommend an in-office or at-home desensitizing agent and advise on a soft-bristle brush and modified brushing technique.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Manage root sensitivity in-house"
        },
        {
          "detail": "Document the recession and attached gingiva measurements, sensitivity findings, and whether the case was managed in-house or referred.\n\nRecord: recession assessment and management/referral decision in the clinical note",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the assessment and management or referral decision"
        },
        {
          "detail": "Recession and mucogingival assessment complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Recession and mucogingival assessment complete"
        },
        {
          "detail": "Prepare and send a referral packet with measurements and photographs to a periodontal specialist for a grafting or mucogingival surgery evaluation.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Refer for a soft-tissue grafting evaluation"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Gingival recession and mucogingival assessment with grafting referral — Recession is noted at exam or a patient reports root sensitivity or an esthetic concern.",
      "title": "Gingival recession and mucogingival assessment with grafting referral",
      "trigger": "Recession is noted at exam or a patient reports root sensitivity or an esthetic concern",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal exam basis for probing and staging)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal exam basis for probing and staging)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "perio-009",
      "kind": "clinical",
      "materials": [
        "periodontal probe",
        "study models or digital scan",
        "radiograph showing bone level",
        "referral form and chart summary"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "During crown or core build-up planning, measure the distance from the finish line to the bone crest; a margin closer than about 3mm to bone or a ferrule under roughly 1.5-2mm of sound tooth structure signals a violation.\n\nWhy: Restoring into the biologic width causes chronic inflammation that will not resolve no matter how well the crown margin is finished.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify insufficient ferrule or biologic width violation",
          "why": "Restoring into the biologic width causes chronic inflammation that will not resolve no matter how well the crown margin is finished."
        },
        {
          "detail": "Probe the sulcus depth and bone-to-margin distance circumferentially and take a periapical radiograph and clinical photo of the tooth.\n\nRecord: Probing measurements, radiograph and photo attached to the encounter",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Measure and photograph the site"
        },
        {
          "detail": "Is this within the practice's in-house surgical scope?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "refer",
              "label": "Refer to a periodontist or oral surgeon for crown lengthening"
            },
            {
              "goto": "s13",
              "id": "in-house",
              "label": "Perform in-house if within trained scope and practice policy"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this within the practice's in-house surgical scope?"
        },
        {
          "detail": "Confirm the patient understands the reason for crown lengthening and the healing timeline before final restoration, and consents to the practice sharing chart notes, radiograph and photo with the receiving specialist office, before the referral packet is prepared or sent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent before preparing or sending the referral.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent before preparing or sending the referral"
        },
        {
          "detail": "Complete a referral form with the tooth number, restorative goal, current biologic width measurement, and attach the radiograph and photo.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the referral packet"
        },
        {
          "detail": "Transmit the referral packet to the receiving specialist's office and confirm receipt with the patient's preferred contact method.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Send referral to periodontist or oral surgeon"
        },
        {
          "detail": "Track whether referral or in-house procedure is complete",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "referral-done",
              "label": "Specialist procedure completed, wait for healing"
            },
            {
              "goto": "s8",
              "id": "in-house-done",
              "label": "In-house procedure completed today, wait for healing"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Track whether referral or in-house procedure is complete"
        },
        {
          "detail": "Allow a minimum 4-week healing window for soft tissue and bone remodeling before restorative re-evaluation; the operating surgeon's post-op instructions govern the exact timing for a given case.\n\nWhy: Prepping or seating a final restoration on unhealed tissue leads to margin placement error and recurrent inflammation as the tissue continues to remodel.",
          "id": "s8",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 2419200,
          "title": "Wait for soft tissue and bone healing before final restoration",
          "why": "Prepping or seating a final restoration on unhealed tissue leads to margin placement error and recurrent inflammation as the tissue continues to remodel."
        },
        {
          "detail": "Re-probe the site to confirm adequate biologic width and ferrule are established before finalizing the crown preparation.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Restorative re-evaluation appointment"
        },
        {
          "detail": "Log the referral date, specialist findings if received, healing check result, and readiness for final crown prep in the chart.\n\nRecord: Referral coordination and re-evaluation note in the chart",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document coordination outcome"
        },
        {
          "detail": "Log the referral-to-completion interval and restorative re-evaluation outcome to the practice's clinical metrics tracker.\n\nRecord: Metrics entry for crown-lengthening coordination",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log crown-lengthening coordination metrics"
        },
        {
          "detail": "Crown lengthening coordination complete",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Crown lengthening coordination complete"
        },
        {
          "detail": "Confirm the patient understands the reason for crown lengthening, the healing timeline before final restoration, and has signed consent on file for the in-house procedure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent before an in-house surgical step.",
            "type": "safety"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent before an in-house surgical step"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Crown lengthening referral and restorative coordination — Insufficient ferrule or a biologic width violation is found before a crown.",
      "title": "Crown lengthening referral and restorative coordination",
      "trigger": "Insufficient ferrule or a biologic width violation is found before a crown",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during soft-tissue surgery)",
          "source": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during soft-tissue surgery)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.1-5.2 (in-repo periodontal exam and instrument-technique basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.1-5.2 (in-repo periodontal exam and instrument-technique basis)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "perio-010",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "soft-tissue laser or scalpel and sutures",
        "gauze",
        "periodontal dressing (optional)",
        "post-op instruction sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Document the specific finding driving the procedure: a diastema associated with a high labial frenum, recession worsened by frenal pull, or a lingual frenum causing tongue-tie symptoms.\n\nWhy: The indication determines which frenum is treated and shapes the post-op functional expectations discussed with the patient.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the clinical indication for frenectomy",
          "why": "The indication determines which frenum is treated and shapes the post-op functional expectations discussed with the patient."
        },
        {
          "detail": "Confirm signed consent covering the procedure, expected healing, alternative of monitoring without treatment, and (for tongue-tie cases) that this is a functional soft-tissue procedure, not a speech-therapy substitute.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent before any incision.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent before any incision"
        },
        {
          "detail": "Administer local anesthetic to the frenum and surrounding tissue and confirm profound anesthesia before proceeding.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Select laser or scalpel technique",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "laser",
              "label": "Soft-tissue laser excision"
            },
            {
              "goto": "s5",
              "id": "scalpel",
              "label": "Scalpel excision with sutures"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Select laser or scalpel technique"
        },
        {
          "detail": "Excise the frenal attachment to the appropriate depth, releasing the pull on the involved papilla or tongue mobility, while preserving surrounding healthy tissue.\n\nWhy: Under-releasing leaves the pull that caused the problem; over-excising risks unnecessary tissue loss and scarring.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Excise the frenum",
          "why": "Under-releasing leaves the pull that caused the problem; over-excising risks unnecessary tissue loss and scarring."
        },
        {
          "detail": "Apply pressure with gauze, place sutures if a scalpel technique was used, and confirm bleeding has stopped before the patient leaves the chair.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Achieve hemostasis and place sutures if needed"
        },
        {
          "detail": "Explain expected mild swelling and soreness, a soft diet for a few days, gentle oral hygiene around the site, and to call the office for increasing pain, swelling or bleeding that does not stop with pressure.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Was this a lingual frenectomy for tongue-tie?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "yes-stretches",
              "label": "Provide tongue-stretching exercise instructions and myofunctional therapy referral"
            },
            {
              "goto": "s9",
              "id": "no",
              "label": "Not a tongue-tie case, no exercise instructions needed"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Was this a lingual frenectomy for tongue-tie?"
        },
        {
          "detail": "Log the indication, frenum treated, technique used, anesthetic, and post-op instructions given in the SOAP note.\n\nRecord: Procedure note with indication, technique and instructions",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Schedule a follow-up check within about 2 weeks to confirm healing and, for tongue-tie cases, functional improvement.",
          "id": "s10",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1209600,
          "title": "Schedule and wait for the post-op follow-up"
        },
        {
          "detail": "Log the indication, technique, and follow-up healing result to the practice's clinical metrics tracker.\n\nRecord: Metrics entry for frenectomy tracking",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Log frenectomy outcome metrics"
        },
        {
          "detail": "Frenectomy complete",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Frenectomy complete"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Frenectomy (GP-delivered) with laser or scalpel — A high frenum attachment is causing a diastema, recession or tongue-tie symptoms.",
      "title": "Frenectomy (GP-delivered) with laser or scalpel",
      "trigger": "A high frenum attachment is causing a diastema, recession or tongue-tie symptoms",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during soft-tissue surgery)",
          "source": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during soft-tissue surgery)"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal exam basis for probing and staging)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.1 (in-repo periodontal exam basis for probing and staging)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "perio-011",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "periodontal probe",
        "electrosurgery unit, laser or scalpel and periodontal knives",
        "periodontal dressing",
        "gauze",
        "post-op instruction sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Measure the width of attached gingiva around the overgrowth; gingivectomy is appropriate only when enough attached gingiva will remain after tissue removal to protect the underlying bone.\n\nWhy: Removing tissue below the mucogingival junction leaves an unattached, mobile margin that will not hold up under function.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm adequate attached gingiva before planning excisional surgery",
          "why": "Removing tissue below the mucogingival junction leaves an unattached, mobile margin that will not hold up under function."
        },
        {
          "detail": "Is the overgrowth drug-induced?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "drug-induced",
              "label": "Drug-induced overgrowth — note causative medication and consider a physician consult"
            },
            {
              "goto": "s4",
              "id": "inflammatory",
              "label": "Inflammatory or hereditary overgrowth — no medication review needed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the overgrowth drug-induced?"
        },
        {
          "detail": "Record the suspected causative medication (commonly certain anticonvulsants, calcium channel blockers, or immunosuppressants) and note whether a physician consult about alternatives is appropriate before or alongside surgery.\n\nWhy: Surgery without addressing a continuing causative medication has a high recurrence rate.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Note the causative medication and consider a physician consult",
          "why": "Surgery without addressing a continuing causative medication has a high recurrence rate."
        },
        {
          "detail": "Confirm signed consent covering the procedure, expected healing time, use of a periodontal dressing if planned, and recurrence risk if a causative medication continues.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent before any incision.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent before any incision"
        },
        {
          "detail": "Administer local anesthetic to the surgical area and confirm profound anesthesia before proceeding.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Use a pocket marker or probe to mark bleeding points on the outer gingival surface corresponding to the base of each pseudo-pocket, establishing the incision line.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Mark pocket depths with a pocket marker or probe"
        },
        {
          "detail": "Excise tissue along the marked line using electrosurgery, laser or a periodontal knife, re-contouring to a physiologic gingival architecture.\n\nWhy: A properly re-contoured margin is easier for the patient to keep clean and reduces the chance of overgrowth recurring in the same shape.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Excise excess gingival tissue",
          "why": "A properly re-contoured margin is easier for the patient to keep clean and reduces the chance of overgrowth recurring in the same shape."
        },
        {
          "detail": "Apply pressure with gauze, confirm bleeding has stopped, and place a periodontal dressing over the site if that is the practice's protocol.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Achieve hemostasis and place dressing if planned"
        },
        {
          "detail": "Explain expected tenderness for several days, a soft diet, gentle brushing around (not directly on) the surgical site, chlorhexidine rinse if prescribed, and when to call the office.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Log the cause (drug-induced or inflammatory), attached-gingiva measurement, technique used, and post-op instructions in the SOAP note.\n\nRecord: Procedure note with cause, technique and instructions",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Schedule a follow-up check within about 2 weeks (this timer covers that follow-up wait) to remove dressing if placed and confirm healing; separately, set a 6-month recall for drug-induced cases to watch for recurrence.",
          "id": "s11",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1209600,
          "title": "Schedule and wait for the post-op follow-up"
        },
        {
          "detail": "Log the cause, technique, and recurrence status at recall to the practice's clinical metrics tracker.\n\nRecord: Metrics entry for gingivectomy/gingivoplasty tracking",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Log gingivectomy outcome metrics"
        },
        {
          "detail": "Gingivectomy or gingivoplasty complete",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Gingivectomy or gingivoplasty complete"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Gingivectomy or gingivoplasty for pseudo-pockets or overgrowth — Drug-induced or inflammatory gingival overgrowth with adequate attached gingiva.",
      "title": "Gingivectomy or gingivoplasty for pseudo-pockets or overgrowth",
      "trigger": "Drug-induced or inflammatory gingival overgrowth with adequate attached gingiva",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "source": "AAP 2017 classification and AAP clinical practice guideline on non-surgical treatment",
          "url": "https://www.perio.org/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis: instrumentation, probing force, recall, referral triggers)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §5.3 (in-repo implant maintenance basis: instrumentation, probing force, recall, referral triggers)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during instrumentation)",
          "source": "OSHA 29 CFR 1910.1030 (aerosol and bloodborne exposure during instrumentation)"
        }
      ],
      "class": "periodontics",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "perio-012",
      "kind": "clinical",
      "materials": [
        "titanium or plastic periodontal probe (never stainless steel on titanium)",
        "periapical radiograph",
        "titanium curettes or plastic scalers",
        "air polisher with glycine or erythritol powder",
        "chlorhexidine or other antimicrobial rinse",
        "referral form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Probe using a titanium or plastic probe with light force (approximately 0.25N) at multiple sites around the implant, recording probing depth, bleeding on probing, and any suppuration; never use a stainless steel scaler on the implant surface.\n\nWhy: Metal instrumentation scratches the implant surface and creates a rougher surface that attracts more biofilm, worsening the problem it is meant to treat.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Perform a gentle peri-implant probing exam",
          "why": "Metal instrumentation scratches the implant surface and creates a rougher surface that attracts more biofilm, worsening the problem it is meant to treat."
        },
        {
          "detail": "Take a periapical radiograph and compare the crestal bone level to the implant's baseline post-restoration film to identify any bone loss.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Compare current radiograph to baseline bone level"
        },
        {
          "detail": "Stage the findings: mucositis or peri-implantitis?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "mucositis",
              "label": "Bleeding on probing with no radiographic bone loss beyond initial remodeling — peri-implant mucositis"
            },
            {
              "goto": "s9",
              "id": "peri-implantitis",
              "label": "Bleeding or suppuration WITH progressive radiographic bone loss — peri-implantitis"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Stage the findings: mucositis or peri-implantitis?"
        },
        {
          "detail": "Disrupt biofilm with a titanium curette or plastic scaler and an air polisher using glycine or erythritol powder appropriate for implant surfaces, and review oral hygiene technique around the implant with the patient.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Provide non-surgical biofilm removal"
        },
        {
          "detail": "Schedule a shorter recall interval, commonly 3 months initially, to re-check bleeding resolution before returning to the standard interval.\n\nWhy: Mucositis is reversible with good hygiene and closer monitoring, but left unchecked it can progress to peri-implantitis.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Shorten the recall interval",
          "why": "Mucositis is reversible with good hygiene and closer monitoring, but left unchecked it can progress to peri-implantitis."
        },
        {
          "detail": "Log probing findings, suppuration, radiographic comparison, stage (mucositis vs peri-implantitis), and the chosen management or referral path in the chart.\n\nRecord: Peri-implant staging and management note in the chart",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document the staging and management plan"
        },
        {
          "detail": "Log the staging outcome and referral or in-house management status to the practice's clinical metrics tracker.\n\nRecord: Metrics entry for peri-implant disease tracking",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log peri-implant disease metrics"
        },
        {
          "detail": "Peri-implant assessment and management complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Peri-implant assessment and management complete"
        },
        {
          "detail": "Confirm the patient understands the diagnosis, the risk of implant loss if untreated, and consents to the chosen path — an in-house procedure or a referral (including sharing probing findings, suppuration status and radiographs with the receiving specialist) — before that path is prepared or begun.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent before any peri-implantitis intervention or referral commitment.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent before any peri-implantitis intervention or referral commitment"
        },
        {
          "detail": "Is surgical or advanced peri-implantitis therapy within in-house scope?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "refer-out",
              "label": "Refer to a periodontist or oral surgeon"
            },
            {
              "goto": "s13",
              "id": "in-house",
              "label": "Manage in-house if within trained scope and practice policy"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Is surgical or advanced peri-implantitis therapy within in-house scope?"
        },
        {
          "detail": "Complete a referral form with the implant site, probing findings, suppuration status, and radiographs showing bone-loss progression.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the referral packet"
        },
        {
          "detail": "Transmit the referral packet to the receiving specialist's office and confirm the patient has scheduled or been contacted.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Send referral to periodontist or oral surgeon"
        },
        {
          "detail": "Provide non-surgical decontamination and, if within scope and indicated, surgical access for debridement and defect management per the practice's trained protocol.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Perform in-house peri-implantitis therapy"
        }
      ],
      "subclass": "periodontal-nonsurgical-and-surgical-care",
      "summary": "Peri-implant mucositis and peri-implantitis staging and management — An implant site shows bleeding on probing, suppuration or radiographic bone loss.",
      "title": "Peri-implant mucositis and peri-implantitis staging and management",
      "trigger": "An implant site shows bleeding on probing, suppuration or radiographic bone loss",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for call-flow structure (greeting, need, schedule, confirm) — no institute script reproduced, and this structure carries no legal authority for records-disclosure or media/attorney/law-enforcement handling decisions made on those same calls — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "The source's own text is 'Generic functional equivalent for call scripts ... no institute script reproduced' — it never claimed to be a legal authority. WebSearch and the audit confirm the real authority for records access is HIPAA 45 CFR 164.524, and for media/attorney/law-enforcement calls it is a mix of HIPAA disclosure rules and practice policy — none of which this generic call-flow template states or incorporates. I could not find text in this source supporting any legal-compliance claim for ph-009 or ph-010, so it stays generic rather than being upgraded to a citation it cannot support.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent for call scripts (greeting, need, schedule, confirm) — no institute script reproduced",
              "url": null
            }
          },
          "source": "Generic functional equivalent for call-flow structure only (greeting, need, schedule, confirm) — generic functional equivalent"
        },
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts/calls, opt-out honoring",
          "source": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts/calls, opt-out honoring",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 8,
      "frequency": "per-use",
      "id": "ph-001",
      "kind": "operational",
      "materials": [
        "phone system with caller ID",
        "practice management system scheduling module",
        "new-patient intake script",
        "insurance verification worksheet",
        "office hours and location reference sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Answer within three rings: 'Thank you for calling [practice], this is [name], how can I help you today?'\n\nWhy: A prompt, branded greeting sets the caller's first impression and confirms they reached the right office.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Answer with the practice name, your name, and a warm greeting",
          "why": "A prompt, branded greeting sets the caller's first impression and confirms they reached the right office."
        },
        {
          "detail": "Confirm the caller is new to the practice, then ask what prompted the call (checkup, pain, cosmetic interest, insurance question).\n\nWhy: Routing new vs. existing correctly avoids a duplicate record and directs the call to the right next step.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Ask if they've been seen before and identify the reason for calling",
          "why": "Routing new vs. existing correctly avoids a duplicate record and directs the call to the right next step."
        },
        {
          "detail": "Listen for emergency language before continuing the routine intake.\n\nWhy: A new-patient call can still be a dental emergency; emergency symptoms must be re-routed before scheduling proceeds.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "opt-routine",
              "label": "No emergency symptoms described"
            },
            {
              "goto": "s11",
              "id": "opt-emergency",
              "label": "Emergency symptoms described"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the caller describe pain, swelling, trauma or bleeding?",
          "why": "A new-patient call can still be a dental emergency; emergency symptoms must be re-routed before scheduling proceeds."
        },
        {
          "detail": "Full name, date of birth, phone, email, address, referral source, insurance carrier and member ID if available, and preferred appointment days/times.\n\nWhy: Capturing this once on the call avoids repeat calls and speeds check-in on the visit day.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Collect new-patient intake information",
          "why": "Capturing this once on the call avoids repeat calls and speeds check-in on the visit day."
        },
        {
          "detail": "Describe arrival time (15 minutes early for paperwork), what to bring (ID, insurance card, medication list), and approximate visit length.\n\nWhy: Setting expectations reduces no-shows and late arrivals.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Explain what to expect and what to bring to the first visit",
          "why": "Setting expectations reduces no-shows and late arrivals."
        },
        {
          "detail": "Search the schedule for openings that fit the reported reason for visit and the caller's stated availability; offer two to three options.\n\nWhy: Offering a small set of concrete times moves the call to a decision faster than asking open-ended availability questions.",
          "id": "s6",
          "kind": "step",
          "role": "scheduler",
          "title": "Offer available appointment times matching the caller's stated need",
          "why": "Offering a small set of concrete times moves the call to a decision faster than asking open-ended availability questions."
        },
        {
          "detail": "Enter the visit type, provider, and confirmed time; flag the chart as new patient.\n\nWhy: A correctly typed visit reason lets the clinical team prepare and prevents under- or over-booking the chair.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Book the appointment in the practice management system",
          "why": "A correctly typed visit reason lets the clinical team prepare and prevents under- or over-booking the chair."
        },
        {
          "detail": "Enter call date/time, caller name, reason for call, appointment booked (yes/no) and time, and referral source into the practice management system.\n\nWhy: A logged call outcome feeds the daily phone metrics review (ph-012) and referral-source tracking.\n\nRecord: Call date/time, caller name, reason for call, appointment booked (yes/no) and time, referral source.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the call outcome in the practice management system",
          "why": "A logged call outcome feeds the daily phone metrics review (ph-012) and referral-source tracking."
        },
        {
          "detail": "Repeat the date, time, and location back to the caller and let them know a confirmation text or email will be sent per their consented contact method.\n\nWhy: Verbal read-back catches transcription errors before the caller hangs up.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the appointment verbally and note that a reminder will follow",
          "why": "Verbal read-back catches transcription errors before the caller hangs up."
        },
        {
          "detail": "New-patient appointment booked and logged",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "New-patient appointment booked and logged"
        },
        {
          "detail": "Pause the new-patient intake and follow protocol ph-003 (dental emergency call triage) instead; return to intake only after the emergency path is resolved.\n\nWhy: Emergency triage takes priority over routine scheduling; using a single dedicated protocol avoids conflicting instructions.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the emergency call triage protocol",
          "why": "Emergency triage takes priority over routine scheduling; using a single dedicated protocol avoids conflicting instructions."
        },
        {
          "detail": "Call continues under the emergency triage protocol",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Call continues under the emergency triage protocol"
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "New patient inbound call — The phone rings from a caller who has never been seen and wants information or an appointment.",
      "title": "New patient inbound call",
      "trigger": "The phone rings from a caller who has never been seen and wants information or an appointment",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.514(d) minimum necessary and 164.524 right of access for records requests by phone",
          "source": "HIPAA 45 CFR 164.514(d) minimum necessary and 164.524 right of access for records requests by phone",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "ph-002",
      "kind": "operational",
      "materials": [
        "phone system with caller ID",
        "practice management system (schedule, ledger, chart notes)",
        "identity verification checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Answer within three rings: 'Thank you for calling [practice], this is [name].'\n\nWhy: Consistent greeting confirms the caller reached the right office before any account information is discussed.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Answer and greet the caller by practice name",
          "why": "Consistent greeting confirms the caller reached the right office before any account information is discussed."
        },
        {
          "detail": "Ask for name and date of birth, search the practice management system, and confirm at least one additional identifier (phone or address on file) before discussing any account detail.\n\nWhy: Verifying identity before disclosing schedule, balance, or clinical detail prevents disclosing PHI to the wrong person.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Locate the patient's chart and verify identity",
          "why": "Verifying identity before disclosing schedule, balance, or clinical detail prevents disclosing PHI to the wrong person."
        },
        {
          "detail": "Listen for emergency language before continuing routine scheduling, billing, or message-taking.\n\nWhy: An existing patient calling in is at least as likely to be reporting a dental emergency as a new patient; emergency symptoms must be re-routed before any routine purpose sorting proceeds.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "opt-routine",
              "label": "No emergency symptoms described"
            },
            {
              "goto": "s8",
              "id": "opt-emergency",
              "label": "Emergency symptoms described"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the caller describe pain, swelling, trauma or bleeding?",
          "why": "An existing patient calling in is at least as likely to be reporting a dental emergency as a new patient; emergency symptoms must be re-routed before any routine purpose sorting proceeds."
        },
        {
          "detail": "Sort the call into scheduling, billing/balance, or a clinical question for the doctor or hygienist.\n\nWhy: Different needs route to different next steps; sorting first avoids a long undirected conversation.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "opt-schedule",
              "label": "Scheduling change or new appointment"
            },
            {
              "goto": "s10",
              "id": "opt-balance",
              "label": "Billing or balance question"
            },
            {
              "goto": "s11",
              "id": "opt-clinical",
              "label": "Clinical question for the doctor or hygienist"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "What does the caller need?",
          "why": "Different needs route to different next steps; sorting first avoids a long undirected conversation."
        },
        {
          "detail": "Make the requested schedule change in the practice management system and confirm the new date/time back to the caller.\n\nWhy: Same-call resolution reduces repeat calls and no-shows caused by unclear scheduling.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Update, book, or reschedule the appointment",
          "why": "Same-call resolution reduces repeat calls and no-shows caused by unclear scheduling."
        },
        {
          "detail": "Enter call date/time, caller, purpose, resolution or handoff, and any callback promised into the practice management system.\n\nWhy: A logged outcome supports the callback cadence protocol (ph-004) and daily phone metrics (ph-012).\n\nRecord: Call date/time, caller, purpose, resolution or handoff, and any callback promised.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the call outcome",
          "why": "A logged outcome supports the callback cadence protocol (ph-004) and daily phone metrics (ph-012)."
        },
        {
          "detail": "Call resolved or routed, and logged",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Call resolved or routed, and logged"
        },
        {
          "detail": "Pause routine handling and follow protocol ph-003 (dental emergency call triage) instead; return to routine scheduling, billing, or message-taking only after the emergency path is resolved.\n\nWhy: Emergency triage takes priority over routine account handling; using a single dedicated protocol avoids conflicting instructions.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the emergency call triage protocol",
          "why": "Emergency triage takes priority over routine account handling; using a single dedicated protocol avoids conflicting instructions."
        },
        {
          "detail": "Call continues under the emergency triage protocol",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Call continues under the emergency triage protocol"
        },
        {
          "detail": "Open the patient ledger, state the current balance and what it covers, and offer payment options if the caller wants to pay by phone.\n\nWhy: A clear balance explanation avoids disputes and speeds collection.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Review the ledger and answer the balance question",
          "why": "A clear balance explanation avoids disputes and speeds collection."
        },
        {
          "detail": "Record the question and callback number, and place the message in the clinical team's inbox or task queue for same-day review; do not answer clinical questions at the desk.\n\nWhy: Clinical questions require a licensed provider's judgment; front desk stays within its scope.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Take a detailed message and route to the clinical team",
          "why": "Clinical questions require a licensed provider's judgment; front desk stays within its scope."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Existing patient inbound call (appointment, question, balance) — An active patient calls about scheduling, a bill, a clinical question or a message for the doctor.",
      "title": "Existing patient inbound call (appointment, question, balance)",
      "trigger": "An active patient calls about scheduling, a bill, a clinical question or a message for the doctor",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For rule-based emergency phone triage — no institute script reproduced; severity 8+/life-threatening symptoms route to emergency services before any clinical advice — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for rule-based emergency phone triage — no institute script reproduced; severity 8+/life-threatening symptoms route to emergency services before any clinical advice"
          },
          "source": "For rule-based emergency phone triage — no institute script reproduced; severity 8+/life-threatening symptoms route to emergency services before any clinical advice — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.512(j) — permitted disclosures to avert a serious and imminent threat to health or safety (e.g., alerting EMS)",
          "source": "HIPAA 45 CFR 164.512(j) — permitted disclosures to avert a serious and imminent threat to health or safety (e.g., alerting EMS)",
          "url": "https://www.ecfr.gov/current/title-45/section-164.512"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 6,
      "frequency": "per-use",
      "id": "ph-003",
      "kind": "operational",
      "materials": [
        "phone system",
        "rule-based emergency triage script/decision tree",
        "provider on-call schedule",
        "practice management system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the caller reports airway swelling/difficulty breathing, uncontrolled bleeding that won't stop with pressure, or loss of consciousness, immediately tell the caller to hang up and call 911 (or stay on the line and call 911 on another line) before any other step. Do not attempt to schedule or advise.\n\nWhy: Rule-based triage runs before any clinical judgment or scheduling; life safety always outranks the appointment book.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Life-threatening symptoms? Call or direct the caller to 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Life-threatening symptoms? Call or direct the caller to 911 first",
          "why": "Rule-based triage runs before any clinical judgment or scheduling; life safety always outranks the appointment book."
        },
        {
          "detail": "Ask the scripted questions (location, duration, swelling, fever, trauma cause) and match the answer to the decision tree's same-day, next-day, or routine branch.\n\nWhy: A fixed decision tree, not free-form judgment, keeps triage consistent and defensible.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-sameday",
              "label": "Severe pain, visible swelling, or trauma — same-day"
            },
            {
              "goto": "s7",
              "id": "opt-nextday",
              "label": "Moderate symptoms — next available slot"
            },
            {
              "goto": "s8",
              "id": "opt-routine",
              "label": "Mild or resolved symptom — routine scheduling"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Classify the reported symptom using the rule-based script",
          "why": "A fixed decision tree, not free-form judgment, keeps triage consistent and defensible."
        },
        {
          "detail": "Use the practice's designated emergency slot or ask the on-call provider whether to work the patient in; confirm the time with the caller.\n\nWhy: Same-day access for severe symptoms reduces the chance the patient goes to an emergency room for a dental-only problem.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Hold or open a same-day emergency slot",
          "why": "Same-day access for severe symptoms reduces the chance the patient goes to an emergency room for a dental-only problem."
        },
        {
          "detail": "The on-call or treating dentist reviews the reported symptoms and the slot held before the patient arrives, and approves any interim guidance beyond the standard script.\n\nWhy: Clinical judgment about symptom severity and any advice beyond the fixed script requires a licensed provider, never front-desk discretion alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Provider confirms the same-day emergency slot and any phone guidance given.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Provider confirms the same-day emergency slot and any phone guidance given",
          "why": "Clinical judgment about symptom severity and any advice beyond the fixed script requires a licensed provider, never front-desk discretion alone."
        },
        {
          "detail": "Enter call time, reported symptoms, triage branch taken, whether EMS was routed, and the appointment or referral outcome into the practice management system.\n\nWhy: A complete triage log supports quality review and protects the practice if the outcome is later questioned.\n\nRecord: Call time, reported symptoms, triage branch taken, EMS routed (yes/no), appointment or referral outcome.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the triage call and outcome",
          "why": "A complete triage log supports quality review and protects the practice if the outcome is later questioned."
        },
        {
          "detail": "Emergency call triaged and outcome logged",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Emergency call triaged and outcome logged"
        },
        {
          "detail": "Book the next available slot. Do not offer self-care, medication, or comfort-measure suggestions of any kind — that content is reviewed for the same-day branch only and is not front-desk scope here. Tell the caller to call back or seek urgent/emergency care if symptoms worsen before the appointment.\n\nWhy: Front desk stays within a scripted, non-diagnostic boundary with nothing left unreviewed; any interim guidance beyond booking requires a licensed provider's sign-off, which this branch does not route through.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer the next available appointment and stay within scripted, non-clinical limits",
          "why": "Front desk stays within a scripted, non-diagnostic boundary with nothing left unreviewed; any interim guidance beyond booking requires a licensed provider's sign-off, which this branch does not route through."
        },
        {
          "detail": "Continue under ph-001 or ph-002 for a routine appointment.\n\nWhy: Mild or resolved symptoms don't need emergency handling once triaged.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Route to routine scheduling protocol",
          "why": "Mild or resolved symptoms don't need emergency handling once triaged."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Dental emergency call triage (rule-based, EMS first) — A caller reports pain, swelling, trauma or bleeding — airway swelling, uncontrolled bleeding or loss of consciousness route to 911 before anything else; otherwise the same-day / next-day decision tree runs.",
      "title": "Dental emergency call triage (rule-based, EMS first)",
      "trigger": "A caller reports pain, swelling, trauma or bleeding — airway swelling, uncontrolled bleeding or loss of consciousness route to 911 before anything else; otherwise the same-day / next-day decision tree runs",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts/calls, opt-out honoring",
          "source": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts/calls, opt-out honoring",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "ph-004",
      "kind": "operational",
      "materials": [
        "phone system voicemail box",
        "patient portal message queue",
        "text/SMS platform with opt-in records",
        "practice management system"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Check all three inbound message channels at set points through the day (opening, mid-morning, after lunch, mid-afternoon, before close) rather than only when idle. Where the phone or portal system supports it, layer a real-time keyword alert (voicemail transcription or text scan for pain/swelling/bleeding/trauma terms) on top of the fixed schedule so an emergency message is not left waiting for the next check point.\n\nWhy: A fixed check schedule prevents messages from sitting unnoticed during busy stretches; a real-time alert closes the gap the fixed schedule alone leaves for a message that arrives right after a check point.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Check voicemail, portal, and text queues on a fixed schedule",
          "why": "A fixed check schedule prevents messages from sitting unnoticed during busy stretches; a real-time alert closes the gap the fixed schedule alone leaves for a message that arrives right after a check point."
        },
        {
          "detail": "Scan the message content for pain, swelling, bleeding, or trauma language.\n\nWhy: A voicemail or text can carry an emergency just as a live call can; it must not wait for the normal one-hour cadence.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-routine-msg",
              "label": "No emergency language"
            },
            {
              "goto": "s7",
              "id": "opt-emergency-msg",
              "label": "Emergency language present"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the message describe an emergency symptom?",
          "why": "A voicemail or text can carry an emergency just as a live call can; it must not wait for the normal one-hour cadence."
        },
        {
          "detail": "Pull up the patient's chart if identifiable, note the stated reason for the message, and confirm the contact method the sender used.\n\nWhy: Having the chart open before calling back speeds the return call.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Prepare to return the message",
          "why": "Having the chart open before calling back speeds the return call."
        },
        {
          "detail": "Call, text, or portal-reply within one business hour of the message arriving, addressing the stated need.\n\nWhy: A defined turnaround time is a measurable service standard and prevents messages from being forgotten.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Return the message within one business hour",
          "why": "A defined turnaround time is a measurable service standard and prevents messages from being forgotten."
        },
        {
          "detail": "Enter channel, time received, time returned, sender, purpose, and resolution into the practice management system.\n\nWhy: The log feeds the end-of-day metrics review (ph-012) so unreturned messages are caught before close.\n\nRecord: Channel, time received, time returned, sender, purpose, and resolution.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the message and the return",
          "why": "The log feeds the end-of-day metrics review (ph-012) so unreturned messages are caught before close."
        },
        {
          "detail": "Message returned and logged",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Message returned and logged"
        },
        {
          "detail": "Call back right away and follow ph-003 (dental emergency call triage) rather than waiting for the routine cadence.\n\nWhy: Message-based emergencies get the same urgency as a live emergency call.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Call the sender back immediately under the emergency triage protocol",
          "why": "Message-based emergencies get the same urgency as a live emergency call."
        },
        {
          "detail": "Message escalated to emergency triage",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Message escalated to emergency triage"
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Voicemail, portal and text message return cadence — A voicemail, portal or text message arrives — returned within one business hour and logged.",
      "title": "Voicemail, portal and text message return cadence",
      "trigger": "A voicemail, portal or text message arrives — returned within one business hour and logged",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts, opt-out honoring",
          "source": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts, opt-out honoring",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 6,
      "frequency": "per-use",
      "id": "ph-005",
      "kind": "operational",
      "materials": [
        "website lead form or chat widget dashboard",
        "SMS platform with opt-in records",
        "practice management system",
        "lead source tracking sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the lead dashboard, SMS platform, or chat widget as soon as a new-lead notification arrives.\n\nWhy: Fast first response is the single strongest predictor of whether an online lead converts to an appointment.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive the notification of a new web form, text, or chat lead",
          "why": "Fast first response is the single strongest predictor of whether an online lead converts to an appointment."
        },
        {
          "detail": "Scan the form, text, or chat content for pain, swelling, bleeding, or trauma language before starting the normal response/cadence flow.\n\nWhy: A web form, text, or chat lead can describe an active emergency just as a live call can; it must not wait for the normal first-response window or follow-up cadence.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-routine-lead",
              "label": "No emergency language"
            },
            {
              "goto": "s8",
              "id": "opt-emergency-lead",
              "label": "Emergency language present"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the submitted message describe an emergency symptom?",
          "why": "A web form, text, or chat lead can describe an active emergency just as a live call can; it must not wait for the normal first-response window or follow-up cadence."
        },
        {
          "detail": "Reply by the same channel or call within the practice's target window; introduce yourself, acknowledge what they asked about, and offer to schedule.\n\nWhy: A quick, human response converts far better than a delayed or purely automated one.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Respond within the target window using the submitted contact method or a phone call",
          "why": "A quick, human response converts far better than a delayed or purely automated one."
        },
        {
          "detail": "Determine whether the prospective patient answered or replied.\n\nWhy: An unreached lead needs a defined follow-up cadence rather than being dropped.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "opt-reached",
              "label": "Reached — proceed to booking"
            },
            {
              "goto": "s10",
              "id": "opt-not-reached",
              "label": "Not reached on first attempt"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was the lead reached on the first attempt?",
          "why": "An unreached lead needs a defined follow-up cadence rather than being dropped."
        },
        {
          "detail": "Once the lead is reached, finish intake and booking per ph-001.\n\nWhy: Reuses the standard new-patient intake instead of duplicating it.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Continue under the new-patient inbound call protocol",
          "why": "Reuses the standard new-patient intake instead of duplicating it."
        },
        {
          "detail": "Enter lead channel, source campaign if known, time received, time of first response, and outcome into the lead tracking sheet.\n\nWhy: Lead-source logging lets the practice measure which marketing channels actually produce booked patients.\n\nRecord: Lead channel, source campaign if known, time received, time of first response, outcome (booked, follow-up in progress, cold).",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Log the lead source and outcome",
          "why": "Lead-source logging lets the practice measure which marketing channels actually produce booked patients."
        },
        {
          "detail": "Lead responded to and outcome logged",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Lead responded to and outcome logged"
        },
        {
          "detail": "Call back right away and follow ph-003 (dental emergency call triage) rather than the normal lead response window or follow-up cadence.\n\nWhy: A prospective patient describing an emergency gets the same urgency as an existing patient's emergency call.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Call the sender back immediately under the emergency triage protocol",
          "why": "A prospective patient describing an emergency gets the same urgency as an existing patient's emergency call."
        },
        {
          "detail": "Lead escalated to emergency triage",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Lead escalated to emergency triage"
        },
        {
          "detail": "Attempt again by a different channel (e.g., call then text) at set intervals over the next 1–3 days per the practice's cadence before marking the lead cold.\n\nWhy: Most online leads are not reached on the first attempt; a structured cadence recovers a meaningful share of them.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Follow the defined multi-touch follow-up cadence",
          "why": "Most online leads are not reached on the first attempt; a structured cadence recovers a meaningful share of them."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Web form, text or chat lead response — A prospective patient submits an online form, text or chat message.",
      "title": "Web form, text or chat lead response",
      "trigger": "A prospective patient submits an online form, text or chat message",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For handling fee-only calls (acknowledge, range, value of exam, offer to book) — no institute script reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for handling fee-only calls (acknowledge, range, value of exam, offer to book) — no institute script reproduced"
          },
          "source": "For handling fee-only calls (acknowledge, range, value of exam, offer to book) — no institute script reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "Informed by FTC Act §5, 15 U.S.C. §45 principles against unfair or deceptive acts or practices — general guidance against quoting a fee likely to mislead about final treatment cost, not a specific fee-disclosure mandate for this scenario",
          "source": "Informed by FTC Act §5, 15 U.S.C. §45 principles against unfair or deceptive acts or practices — general guidance against quoting a fee likely to mislead about final treatment cost, not a specific fee-disclosure mandate for this scenario",
          "url": "https://www.ftc.gov/legal-library/browse/statutes/federal-trade-commission-act"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "ph-006",
      "kind": "operational",
      "materials": [
        "practice fee schedule reference",
        "insurance benefit lookup tool",
        "value-of-exam talking points"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Thank the caller for asking and confirm which procedure they're asking about.\n\nWhy: Deflecting a direct price question reads as evasive and loses the caller; acknowledging it builds trust.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Acknowledge the question directly rather than deflecting it",
          "why": "Deflecting a direct price question reads as evasive and loses the caller; acknowledging it builds trust."
        },
        {
          "detail": "Some services (e.g., a standard cleaning, a consultation) have a stable quotable range; most restorative or surgical fees depend on an exam and diagnostics.\n\nWhy: Quoting a fee for something that genuinely depends on individual findings sets an inaccurate expectation and can create disputes later.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-quotable",
              "label": "Range can be quoted without an exam"
            },
            {
              "goto": "s8",
              "id": "opt-exam-needed",
              "label": "Fee depends on an exam or diagnostics first"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this a procedure with a quotable fee range without an exam?",
          "why": "Quoting a fee for something that genuinely depends on individual findings sets an inaccurate expectation and can create disputes later."
        },
        {
          "detail": "State the practice's published range for that service and note that insurance benefits, if the caller has coverage, may reduce out-of-pocket cost.\n\nWhy: A concrete range answers the question honestly while leaving room for insurance to change the final number.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Give the quotable fee range and mention insurance may apply",
          "why": "A concrete range answers the question honestly while leaving room for insurance to change the final number."
        },
        {
          "detail": "Offer two to three appointment times for the exam or consultation.\n\nWhy: Ending on a concrete next step converts the price inquiry into a scheduled visit.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer to book the exam or consultation",
          "why": "Ending on a concrete next step converts the price inquiry into a scheduled visit."
        },
        {
          "detail": "Determine whether the caller scheduled an appointment on this call.\n\nWhy: Booked and not-booked calls need different logging and follow-up.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "opt-booked",
              "label": "Booked"
            },
            {
              "goto": "s9",
              "id": "opt-not-booked",
              "label": "Not booked — offer to follow up"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the caller book?",
          "why": "Booked and not-booked calls need different logging and follow-up."
        },
        {
          "detail": "Enter procedure asked about, fee range or exam-needed explanation given, booked (yes/no), and follow-up scheduled if not into the practice management system.\n\nWhy: Tracking price-shopper conversion shows whether the fee-handling script is working.\n\nRecord: Procedure asked about, fee range or exam-needed explanation given, booked (yes/no), follow-up scheduled if not.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the call outcome",
          "why": "Tracking price-shopper conversion shows whether the fee-handling script is working."
        },
        {
          "detail": "Price-shopper call handled and logged",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Price-shopper call handled and logged"
        },
        {
          "detail": "Explain that the fee depends on findings only visible on exam or x-ray, and that the exam itself has a defined, quotable fee; offer to check insurance benefits before the visit.\n\nWhy: Framing the exam as the path to an accurate number, not a stalling tactic, keeps the caller's trust.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Explain why an exam is needed for an accurate estimate",
          "why": "Framing the exam as the path to an accurate number, not a stalling tactic, keeps the caller's trust."
        },
        {
          "detail": "Ask if a follow-up call in a few days or a written fee estimate by email/text would help, and capture contact information if not already on file.\n\nWhy: Not every price-shopper books immediately; a low-friction follow-up option keeps the lead warm.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer a follow-up call or written estimate",
          "why": "Not every price-shopper books immediately; a low-friction follow-up option keeps the lead warm."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Price-shopper call (fee requested before booking) — A caller asks the fee for a procedure before agreeing to be seen.",
      "title": "Price-shopper call (fee requested before booking)",
      "trigger": "A caller asks the fee for a procedure before agreeing to be seen",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For hold/transfer/callback etiquette (ask permission, check back, confirm before transfer, log callback promises) — no institute script reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for hold/transfer/callback etiquette (ask permission, check back, confirm before transfer, log callback promises) — no institute script reproduced"
          },
          "source": "For hold/transfer/callback etiquette (ask permission, check back, confirm before transfer, log callback promises) — no institute script reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent and opt-out honoring, relevant when a promised callback is made by autodialed text",
          "source": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent and opt-out honoring, relevant when a promised callback is made by autodialed text",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 3,
      "frequency": "per-use",
      "id": "ph-007",
      "kind": "operational",
      "materials": [
        "phone system with hold and transfer functions",
        "callback tracking list or task queue"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Determine which of the three situations applies.\n\nWhy: Each situation has a distinct courtesy standard to follow.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "opt-hold",
              "label": "Needs to be placed on hold"
            },
            {
              "goto": "s5",
              "id": "opt-transfer",
              "label": "Needs to be transferred"
            },
            {
              "goto": "s7",
              "id": "opt-callback",
              "label": "Needs a callback later"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does this call need a hold, a transfer, or a callback promise?",
          "why": "Each situation has a distinct courtesy standard to follow."
        },
        {
          "detail": "Say 'May I place you on a brief hold?' and wait for acknowledgment before muting or holding.\n\nWhy: Asking permission, rather than holding without warning, respects the caller and reduces hang-ups.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Ask permission before placing the caller on hold",
          "why": "Asking permission, rather than holding without warning, respects the caller and reduces hang-ups."
        },
        {
          "detail": "If the reason for the hold isn't resolved within 30 seconds, return to the line and give the caller a status update or ask if they'd prefer a callback instead.\n\nWhy: Checking back within 30 seconds prevents the caller from feeling forgotten on hold.",
          "id": "s3",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 30,
          "title": "Wait no more than 30 seconds before checking back",
          "why": "Checking back within 30 seconds prevents the caller from feeling forgotten on hold."
        },
        {
          "detail": "Hold handled with a check-back within 30 seconds",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Hold handled with a check-back within 30 seconds"
        },
        {
          "detail": "Tell the caller who they're being transferred to and why, then speak briefly to the receiving staff member to relay the caller's name and need before connecting the call.\n\nWhy: A warm, briefed transfer avoids making the caller repeat their story from scratch.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Announce the transfer and brief the receiving person before connecting",
          "why": "A warm, briefed transfer avoids making the caller repeat their story from scratch."
        },
        {
          "detail": "Call warmly transferred with context relayed",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Call warmly transferred with context relayed"
        },
        {
          "detail": "Give a specific window (e.g., 'within the hour' or 'before we close today') rather than a vague 'soon,' and add the callback to the task queue with the caller's name and number.\n\nWhy: A specific, tracked promise is more likely to be kept than a vague one, and a written record prevents it being forgotten.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Set a specific, realistic callback window and record it",
          "why": "A specific, tracked promise is more likely to be kept than a vague one, and a written record prevents it being forgotten."
        },
        {
          "detail": "Enter caller, reason, promised callback window, and completion time once returned into the callback tracking list.\n\nWhy: Tracking promised-vs-completed callback time is a direct service-quality metric.\n\nRecord: Caller, reason, promised callback window, and completion time once returned.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the callback promise and later its completion",
          "why": "Tracking promised-vs-completed callback time is a direct service-quality metric."
        },
        {
          "detail": "Callback promised and logged for follow-up",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Callback promised and logged for follow-up"
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Hold, transfer and callback etiquette — Any call needs a hold longer than 30 seconds, a transfer, or a promised callback.",
      "title": "Hold, transfer and callback etiquette",
      "trigger": "Any call needs a hold longer than 30 seconds, a transfer, or a promised callback",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For de-escalation phone etiquette (acknowledge, stay calm, offer to escalate, document) — no institute script reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for de-escalation phone etiquette (acknowledge, stay calm, offer to escalate, document) — no institute script reproduced"
          },
          "source": "For de-escalation phone etiquette (acknowledge, stay calm, offer to escalate, document) — no institute script reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "California Penal Code §632 — all-party consent before recording or AI-processing a call, relevant if the abusive call is recorded as an incident record",
          "source": "California Penal Code §632 — all-party consent before recording or AI-processing a call, relevant if the abusive call is recorded as an incident record",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=632.&lawCode=PEN"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 8,
      "frequency": "as-needed",
      "id": "ph-008",
      "kind": "operational",
      "materials": [
        "de-escalation talking points",
        "incident log form",
        "office manager escalation contact",
        "call recording system if enabled (per ph-011 consent setup)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Do not match the caller's tone; say something like 'I can hear you're frustrated, I want to help you sort this out.'\n\nWhy: Matching an angry tone escalates the call; a calm, acknowledging tone is more likely to de-escalate it.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Stay calm, lower your own volume, and acknowledge the caller's frustration",
          "why": "Matching an angry tone escalates the call; a calm, acknowledging tone is more likely to de-escalate it."
        },
        {
          "detail": "Distinguish frustration and raised voice from an explicit threat of harm.\n\nWhy: A genuine threat requires immediate escalation and documentation for possible law-enforcement involvement; ordinary frustration does not.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "opt-upset-only",
              "label": "Upset but not threatening"
            },
            {
              "goto": "s8",
              "id": "opt-genuine-threat",
              "label": "Genuine threat of harm"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the caller merely upset, or making a genuine threat (violence, harm) toward staff or the practice?",
          "why": "A genuine threat requires immediate escalation and documentation for possible law-enforcement involvement; ordinary frustration does not."
        },
        {
          "detail": "Ask the caller to describe the specific issue, and offer a concrete next step (correcting a bill, rescheduling, escalating to the office manager).\n\nWhy: Most upset calls are resolvable once the specific issue is identified rather than the caller venting in general.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Ask what specifically went wrong and offer to help resolve it",
          "why": "Most upset calls are resolvable once the specific issue is identified rather than the caller venting in general."
        },
        {
          "detail": "Determine whether the issue is within front-desk authority (scheduling, simple billing correction) or needs a supervisor decision (fee waiver, complaint about staff conduct).\n\nWhy: Escalating issues that exceed front-desk authority avoids making promises that can't be kept.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "opt-resolve-here",
              "label": "Resolvable at the desk"
            },
            {
              "goto": "s9",
              "id": "opt-escalate-manager",
              "label": "Needs the office manager"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "Can front desk resolve this, or does it need the office manager?",
          "why": "Escalating issues that exceed front-desk authority avoids making promises that can't be kept."
        },
        {
          "detail": "Make the correction or arrangement and repeat it back to the caller to confirm it addresses their concern.\n\nWhy: Confirming the resolution out loud reduces the chance of a repeat call about the same issue.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Resolve the issue and confirm the resolution with the caller",
          "why": "Confirming the resolution out loud reduces the chance of a repeat call about the same issue."
        },
        {
          "detail": "Enter date/time, caller, nature of the complaint or threat, staff involved, resolution or escalation taken, and whether law enforcement was notified into the incident log.\n\nWhy: A documented pattern of difficult calls supports staff protection decisions and, for genuine threats, a possible legal or police record.\n\nRecord: Date/time, caller, nature of the complaint or threat, staff involved, resolution or escalation taken, and whether law enforcement was notified.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the incident",
          "why": "A documented pattern of difficult calls supports staff protection decisions and, for genuine threats, a possible legal or police record."
        },
        {
          "detail": "Call de-escalated or escalated, and incident logged",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Call de-escalated or escalated, and incident logged"
        },
        {
          "detail": "End the call if the threat continues, immediately notify the office manager, and the office manager decides whether to notify local police and whether any staff safety measure is needed.\n\nWhy: A genuine threat is a supervisor-level decision, not a front-desk call — it can involve staff safety and law enforcement.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager sign-off before ending the call and deciding on law-enforcement notification.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager sign-off before ending the call and deciding on law-enforcement notification",
          "why": "A genuine threat is a supervisor-level decision, not a front-desk call — it can involve staff safety and law enforcement."
        },
        {
          "detail": "Brief the office manager on the caller's issue and history before connecting or having them call back.\n\nWhy: A briefed handoff avoids the caller having to repeat themselves to a second person, which can re-escalate frustration.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Transfer or escalate to the office manager with full context",
          "why": "A briefed handoff avoids the caller having to repeat themselves to a second person, which can re-escalate frustration."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Upset, threatening or abusive caller — A caller is angry, threatening or abusive toward staff.",
      "title": "Upset, threatening or abusive caller",
      "trigger": "A caller is angry, threatening or abusive toward staff",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for call-flow structure (greeting, need, schedule, confirm) — no institute script reproduced, and this structure carries no legal authority for records-disclosure or media/attorney/law-enforcement handling decisions made on those same calls — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "The source's own text is 'Generic functional equivalent for call scripts ... no institute script reproduced' — it never claimed to be a legal authority. WebSearch and the audit confirm the real authority for records access is HIPAA 45 CFR 164.524, and for media/attorney/law-enforcement calls it is a mix of HIPAA disclosure rules and practice policy — none of which this generic call-flow template states or incorporates. I could not find text in this source supporting any legal-compliance claim for ph-009 or ph-010, so it stays generic rather than being upgraded to a citation it cannot support.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent for call scripts (greeting, need, schedule, confirm) — no institute script reproduced",
              "url": null
            }
          },
          "source": "Generic functional equivalent for call-flow structure only (greeting, need, schedule, confirm) — generic functional equivalent"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.514(d) minimum necessary and 164.524 right of access for records requests by phone",
          "source": "HIPAA 45 CFR 164.514(d) minimum necessary and 164.524 right of access for records requests by phone",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.508 — written authorization required before disclosure of PHI to a third party (another office, attorney, insurer)",
          "source": "HIPAA 45 CFR 164.508 — written authorization required before disclosure of PHI to a third party (another office, attorney, insurer)",
          "url": "https://www.ecfr.gov/current/title-45/part-164/subpart-E/section-164.508"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 8,
      "frequency": "as-needed",
      "id": "ph-009",
      "kind": "operational",
      "materials": [
        "records-request log",
        "written-request form / patient portal request path",
        "HIPAA authorization form template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Greet the caller, ask what records or information are needed, and note whether the caller is the patient, another dental office, an attorney, or an insurer.\n\nWhy: Verification and disclosure rules differ depending on who is asking.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Answer the call and identify the request type",
          "why": "Verification and disclosure rules differ depending on who is asking."
        },
        {
          "detail": "Is the caller the patient or a third party?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "patient",
              "label": "Caller is the patient"
            },
            {
              "goto": "s9",
              "id": "third-party",
              "label": "Caller is another office, attorney, or insurer"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the caller the patient or a third party?"
        },
        {
          "detail": "Confirm full legal name, date of birth, and one additional identifier (address or last visit date) without accepting information the caller cannot supply unprompted.\n\nWhy: Confirming identity before discussing any record content prevents disclosure to the wrong person.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify the patient's identity",
          "why": "Confirming identity before discussing any record content prevents disclosure to the wrong person."
        },
        {
          "detail": "No record content is read aloud or released on the call itself. The request is routed to the written or portal channel and cleared for minimum-necessary compliance before anything is sent.\n\nWhy: HIPAA 164.514(d) minimum-necessary standard applies to every disclosure, not just bulk record releases.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance check before any release.",
            "role": "office manager or compliance officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "office-manager",
          "title": "Compliance check before any release",
          "why": "HIPAA 164.514(d) minimum-necessary standard applies to every disclosure, not just bulk record releases."
        },
        {
          "detail": "Give the caller the practice's written-request path (patient portal request form, fax line, or mail) and confirm their preferred delivery method; state a target turnaround time.\n\nWhy: A written, auditable trail satisfies HIPAA 164.524 and protects the practice if the release is later questioned.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Route the caller to the written-request channel",
          "why": "A written, auditable trail satisfies HIPAA 164.524 and protects the practice if the release is later questioned."
        },
        {
          "detail": "Enter the requester, request date, records requested, verification method used, and turnaround target in the records-request log.\n\nRecord: records request log entry (requester, date, scope, verification method, due date)",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the records request"
        },
        {
          "detail": "Every records request that reaches this point — the patient's own verified request and any third-party request alike — is handed to the compliance officer for a final check before fulfillment, not only requests with unclear authorization.\n\nWhy: A second, named reviewer confirms minimum-necessary scope and authorization on every request, including a fully verified patient request, before PHI leaves the practice.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off every logged request to compliance for a final check",
          "why": "A second, named reviewer confirms minimum-necessary scope and authorization on every request, including a fully verified patient request, before PHI leaves the practice."
        },
        {
          "detail": "Records request handled",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Records request handled"
        },
        {
          "detail": "Confirm a signed HIPAA authorization or subpoena is already on file, or explain that one is required before any records can move; log the requester's organization and a callback number.\n\nWhy: HIPAA 45 CFR 164.508 requires written patient authorization before PHI is disclosed to a third party absent another legal basis.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify authorization for a third-party request",
          "why": "HIPAA 45 CFR 164.508 requires written patient authorization before PHI is disclosed to a third party absent another legal basis."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Records, radiograph or referral request received by phone — A patient, another office, an attorney or an insurer asks for records by phone — identity verified, written request routed, no PHI read out unverified.",
      "title": "Records, radiograph or referral request received by phone",
      "trigger": "A patient, another office, an attorney or an insurer asks for records by phone — identity verified, written request routed, no PHI read out unverified",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for call-flow structure (greeting, need, schedule, confirm) — no institute script reproduced, and this structure carries no legal authority for records-disclosure or media/attorney/law-enforcement handling decisions made on those same calls — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "The source's own text is 'Generic functional equivalent for call scripts ... no institute script reproduced' — it never claimed to be a legal authority. WebSearch and the audit confirm the real authority for records access is HIPAA 45 CFR 164.524, and for media/attorney/law-enforcement calls it is a mix of HIPAA disclosure rules and practice policy — none of which this generic call-flow template states or incorporates. I could not find text in this source supporting any legal-compliance claim for ph-009 or ph-010, so it stays generic rather than being upgraded to a citation it cannot support.",
            "ticket": "PROT-017",
            "was": {
              "source": "Generic functional equivalent for call scripts (greeting, need, schedule, confirm) — no institute script reproduced",
              "url": null
            }
          },
          "source": "Generic functional equivalent for call-flow structure only (greeting, need, schedule, confirm) — generic functional equivalent"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.514(d) minimum necessary — no PHI or case detail is confirmed to an unverified caller regardless of stated role",
          "source": "HIPAA 45 CFR 164.514(d) minimum necessary — no PHI or case detail is confirmed to an unverified caller regardless of stated role",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "ph-010",
      "kind": "operational",
      "materials": [
        "incident log",
        "callback-message pad",
        "practice owner and legal counsel contact list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Answer normally; ask the caller to state their name, organization, and reason for the call. Do not confirm any patient's presence, treatment, or any other detail.\n\nWhy: Confirming or denying anything before verifying who is calling can create an unintended admission or PHI disclosure.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Answer the call and identify the caller",
          "why": "Confirming or denying anything before verifying who is calling can create an unintended admission or PHI disclosure."
        },
        {
          "detail": "Does this need an immediate response, or can it wait for the owner?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "routine",
              "label": "Press, attorney, or regulator calling for information — no on-site urgency"
            },
            {
              "goto": "s9",
              "id": "urgent",
              "label": "Law enforcement present on-site or requesting an immediate response"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does this need an immediate response, or can it wait for the owner?"
        },
        {
          "detail": "No statement, confirmation, or PHI is given by anyone other than the practice owner or a designated compliance officer. Front desk takes the caller's contact information and the exact request, and states that a callback will follow.\n\nWhy: An uncoordinated statement to press, opposing counsel, a regulator, or law enforcement creates legal and reputational risk the practice cannot take back.",
          "gate": {
            "ack": "I confirm I have completed this step as written: No statement without owner authorization.",
            "role": "practice owner or designated compliance officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "front-desk",
          "title": "No statement without owner authorization",
          "why": "An uncoordinated statement to press, opposing counsel, a regulator, or law enforcement creates legal and reputational risk the practice cannot take back."
        },
        {
          "detail": "Record the caller's name, organization, callback number, exact stated request, and time of call in the incident log.\n\nRecord: media/legal/regulatory call log entry",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the call"
        },
        {
          "detail": "Pass the logged call details to the practice owner immediately — same business day, sooner if law enforcement is on-site.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand the call to the practice owner"
        },
        {
          "detail": "The practice owner, with legal counsel if the matter is legal or regulatory, decides on and delivers any response. Front desk staff are not involved in the substantive reply.\n\nWhy: Keeping a single authorized voice for the practice avoids conflicting statements.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Owner decides on and delivers any response",
          "why": "Keeping a single authorized voice for the practice avoids conflicting statements."
        },
        {
          "detail": "Record the response given (or that no comment was issued) and file it with the incident log.\n\nRecord: resolution note appended to incident log",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the outcome"
        },
        {
          "detail": "Call handled and logged",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Call handled and logged"
        },
        {
          "detail": "Call or page the practice owner's direct line now, or the office manager if the owner is unreachable within a minute or two — this happens immediately, not at the same-business-day pace of the routine branch, while the caller or on-site officer waits.\n\nWhy: Law enforcement present on-site or demanding an immediate response cannot wait for the routine same-day handoff; the urgency fork has to actually change what happens next, not just what the caller is told.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Escalate immediately, before continuing the script",
          "why": "Law enforcement present on-site or demanding an immediate response cannot wait for the routine same-day handoff; the urgency fork has to actually change what happens next, not just what the caller is told."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Call from media, attorney, regulator or law enforcement handled at the desk — A caller identifies as press, opposing counsel, a board investigator or police — no statement is given; the call is routed to the owner and the time and request are logged.",
      "title": "Call from media, attorney, regulator or law enforcement handled at the desk",
      "trigger": "A caller identifies as press, opposing counsel, a board investigator or police — no statement is given; the call is routed to the owner and the time and request are logged",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Penal Code §632 — all-party consent before recording or AI-processing a call",
          "source": "California Penal Code §632 — all-party consent before recording or AI-processing a call",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=632.&lawCode=PEN"
        },
        {
          "kind": "statute",
          "label": "California AB 3030 (H&S §1339.75) — disclosure on GenAI patient-facing clinical communications unless provider-reviewed",
          "source": "California AB 3030 (H&S §1339.75) — disclosure on GenAI patient-facing clinical communications unless provider-reviewed",
          "url": "https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB3030"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 60,
      "frequency": "once",
      "id": "ph-011",
      "kind": "operational",
      "materials": [
        "greeting/consent disclosure script",
        "retention and telephony vendor settings",
        "pre-launch checklist",
        "compliance log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Decide whether this is call recording only, transcription, and/or an AI call assistant that drafts responses or summaries, and write down which lines or numbers it applies to.\n\nWhy: Consent and disclosure requirements differ by what is actually recorded or AI-processed.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Define exactly what is being turned on",
          "why": "Consent and disclosure requirements differ by what is actually recorded or AI-processed."
        },
        {
          "detail": "Write the disclosure played or spoken before any recording or AI processing begins, e.g. 'this call may be recorded and processed by an assistant for quality and training purposes.'\n\nWhy: California Penal Code §632 requires consent from all parties to a recorded or AI-processed call.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Draft the greeting consent disclosure",
          "why": "California Penal Code §632 requires consent from all parties to a recorded or AI-processed call."
        },
        {
          "detail": "The disclosure must play or be spoken before recording or AI processing starts, not after. All-party consent is confirmed before the feature touches a single real patient call.\n\nWhy: Consent captured after the fact does not satisfy §632.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm all-party consent before go-live.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm all-party consent before go-live",
          "why": "Consent captured after the fact does not satisfy §632."
        },
        {
          "detail": "Configure the recording or transcription system so raw audio is retained for 0 days after transcription completes; transcript text may follow the practice's ordinary records retention policy, but the audio file itself is not kept.\n\nWhy: Minimizing retention of an unencrypted voice recording limits exposure if the system is ever compromised.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Set raw-audio retention to zero",
          "why": "Minimizing retention of an unencrypted voice recording limits exposure if the system is ever compromised."
        },
        {
          "detail": "For any AI-generated content that reaches a patient — a summary, callback script, or automated text — configure the disclosure: 'This message was AI-generated and reviewed by a licensed provider,' unless a licensed provider reviews the content before it goes out.\n\nWhy: California AB 3030 (H&S §1339.75) requires disclosure on GenAI patient-facing clinical communications absent provider review.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Configure the AB 3030 patient-facing disclosure",
          "why": "California AB 3030 (H&S §1339.75) requires disclosure on GenAI patient-facing clinical communications absent provider review."
        },
        {
          "detail": "Confirm: disclosure script tested on a live test call; retention setting verified at 0 days for raw audio; AB 3030 disclosure wired for any patient-facing AI output; opt-out path documented for callers who decline; staff briefed on the change.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the pre-launch checklist"
        },
        {
          "detail": "The compliance officer signs off that every pre-launch checklist item is complete before the system goes live for real patient calls.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before real calls are recorded.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before real calls are recorded"
        },
        {
          "detail": "Enable the recording, transcription, or AI-assist feature for the defined scope and monitor the first day of calls for correct disclosure playback and retention behavior.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Go live and monitor the first day"
        },
        {
          "detail": "Record what was enabled, the effective date, the retention setting, and the sign-off name in the compliance log.\n\nRecord: call-recording/AI-assist setup record (scope, retention, sign-off)",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log what was enabled"
        },
        {
          "detail": "Call recording / AI assist live and documented",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Call recording / AI assist live and documented"
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Enabling call recording, transcription or AI call assistance — The practice turns on call recording, transcription or an AI call assistant — greeting disclosure, all-party consent where required, raw-audio retention set to zero, AB 3030 disclosure for any clinical content.",
      "title": "Enabling call recording, transcription or AI call assistance",
      "trigger": "The practice turns on call recording, transcription or an AI call assistant — greeting disclosure, all-party consent where required, raw-audio retention set to zero, AB 3030 disclosure for any clinical content",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "For a daily phone-metrics review (answer rate, missed calls, callback, conversion) — no vendor analytics platform reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a daily phone-metrics review (answer rate, missed calls, callback, conversion) — no vendor analytics platform reproduced"
          },
          "source": "For a daily phone-metrics review (answer rate, missed calls, callback, conversion) — no vendor analytics platform reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts/calls, opt-out honoring, informs same-day callback practice",
          "source": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent for automated texts/calls, opt-out honoring, informs same-day callback practice",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "daily",
      "id": "ph-012",
      "kind": "operational",
      "materials": [
        "phone system daily report",
        "missed-call callback log",
        "weekly metrics tracker"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "At close of business, pull the day's phone report — total calls, answered, missed, average hold time, and calls converted to booked appointments.\n\nWhy: A same-day pull catches missed calls while a callback is still useful to the patient.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the day's phone report",
          "why": "A same-day pull catches missed calls while a callback is still useful to the patient."
        },
        {
          "detail": "Check answer rate against target, number of missed calls, average time-to-answer, booking conversion rate, and any long-hold outliers.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the day's metrics"
        },
        {
          "detail": "Were there any missed calls today?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Missed calls found"
            },
            {
              "goto": "s6",
              "id": "no",
              "label": "No missed calls"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Were there any missed calls today?"
        },
        {
          "detail": "Call back every number on the missed-call list before end of day, or first thing next business day if after hours; note the outcome of each callback.\n\nWhy: A missed call not returned is a lost patient relationship and a lost booking.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Return every missed call",
          "why": "A missed call not returned is a lost patient relationship and a lost booking."
        },
        {
          "detail": "Log the outcome of each callback (reached, no answer, voicemail left, booked) next to the original missed-call entry.\n\nRecord: missed-call callback log (outcome per number)",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log callback outcomes"
        },
        {
          "detail": "Record the day's answer rate, missed-call count, and conversion rate in the weekly metrics tracker.\n\nRecord: daily phone metrics tracker entry",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the day's metrics"
        },
        {
          "detail": "Is answer rate or conversion trending below target?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "on-target",
              "label": "Metrics within target range"
            },
            {
              "goto": "s9",
              "id": "below-target",
              "label": "Metrics below target for multiple consecutive days"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is answer rate or conversion trending below target?"
        },
        {
          "detail": "Daily phone metrics review complete",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Daily phone metrics review complete"
        },
        {
          "detail": "Flag the sustained answer-rate or conversion shortfall to the practice owner and review staffing or coverage during peak call hours.\n\nWhy: A one-day dip is noise; a multi-day trend signals a coverage or process problem worth fixing.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate a sustained shortfall",
          "why": "A one-day dip is noise; a multi-day trend signals a coverage or process problem worth fixing."
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "Daily phone metrics review (answer rate, missed calls, booking conversion) — End of every day the phone report is reviewed and every missed call is returned.",
      "title": "Daily phone metrics review (answer rate, missed calls, booking conversion)",
      "trigger": "End of every day the phone report is reviewed and every missed call is returned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California AB 3030 (H&S §1339.75) — disclosure on GenAI patient-facing clinical communications unless provider-reviewed",
          "source": "California AB 3030 (H&S §1339.75) — disclosure on GenAI patient-facing clinical communications unless provider-reviewed",
          "url": "https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240AB3030"
        },
        {
          "kind": "generic",
          "label": "For an AI-incident intake, licensed review, correction, and vendor-fix workflow — no vendor incident-response system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for an AI-incident intake, licensed review, correction, and vendor-fix workflow — no vendor incident-response system reproduced"
          },
          "source": "For an AI-incident intake, licensed review, correction, and vendor-fix workflow — no vendor incident-response system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "ph-013",
      "kind": "operational",
      "materials": [
        "incident log",
        "AI/chatbot vendor contact",
        "patient outreach script template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "compliance-officer",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Get the full story from whoever reported it — patient at the desk, a call, or internal noticing — including exactly what the AI said or did and when.\n\nWhy: The correction and any required disclosure both depend on exactly what went wrong.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Capture the full report",
          "why": "The correction and any required disclosure both depend on exactly what went wrong."
        },
        {
          "detail": "Did the AI give clinical advice or just mishandle scheduling?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "clinical",
              "label": "Clinical or health-related content was involved"
            },
            {
              "goto": "s11",
              "id": "scheduling-only",
              "label": "Scheduling or booking error only, no clinical content"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the AI give clinical advice or just mishandle scheduling?"
        },
        {
          "detail": "A licensed dentist reviews any clinically-worded content the AI gave before the practice sends the patient a correction. The correction is never auto-sent.\n\nWhy: An AI system's wrong clinical statement is a patient-safety matter, not just a scheduling fix.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed review before any correction is sent.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed review before any correction is sent",
          "why": "An AI system's wrong clinical statement is a patient-safety matter, not just a scheduling fix."
        },
        {
          "detail": "Contact the patient with the corrected information. If clinical content was wrong, use the dentist-reviewed correction verbatim and include the AB 3030 disclosure: 'This message was AI-generated and has been reviewed by a licensed provider; the earlier automated message contained an error.'\n\nWhy: California AB 3030 (H&S §1339.75) requires disclosure on GenAI patient-facing clinical communications absent provider review.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the patient with the corrected information",
          "why": "California AB 3030 (H&S §1339.75) requires disclosure on GenAI patient-facing clinical communications absent provider review."
        },
        {
          "detail": "Log what the AI said or did, the patient impact, the correction given, and whether clinical review was required, in the incident log.\n\nRecord: AI phone/chat incident log entry",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Send the incident details to the IT vendor or AI system owner so the underlying script, decision tree, or model prompt can be corrected.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the IT vendor for a system fix"
        },
        {
          "detail": "IT vendor confirms and documents the fix — script correction, guardrail added, or system flagged — and reports back before the incident is considered resolved.\n\nWhy: Without a confirmed fix, the same error can recur on the very next call.",
          "id": "s7",
          "kind": "step",
          "role": "it-vendor",
          "title": "Verify the underlying fix",
          "why": "Without a confirmed fix, the same error can recur on the very next call."
        },
        {
          "detail": "The compliance officer confirms the incident log is complete and the fix was verified before the incident is marked closed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance confirms closure.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance confirms closure"
        },
        {
          "detail": "Mark the incident closed with date, fix confirmation, and any patient-facing correction sent, in the compliance log.\n\nRecord: incident closure record",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the incident"
        },
        {
          "detail": "AI incident resolved and closed",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "AI incident resolved and closed"
        },
        {
          "detail": "Create, cancel, or reschedule the appointment as needed to match what the patient actually needs, and confirm the correct time directly with the patient by phone.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Correct the appointment record"
        }
      ],
      "subclass": "phone-and-inbound-communication",
      "summary": "AI phone assistant or chatbot gave a patient wrong information or booked incorrectly — A patient arrives for an appointment the AI never created, or reports advice the chatbot gave that was clinically wrong.",
      "title": "AI phone assistant or chatbot gave a patient wrong information or booked incorrectly",
      "trigger": "A patient arrives for an appointment the AI never created, or reports advice the chatbot gave that was clinically wrong",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "source": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC4086602/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (photos are PHI; storage and disclosure) and 164.508 authorization for marketing use",
          "source": "HIPAA 45 CFR 164 (photos are PHI; storage and disclosure) and 164.508 authorization for marketing use",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.508(a)(3) — a specific written authorization is required before PHI (including photos) is used for marketing, separate from consent to treat",
          "source": "45 CFR 164.508(a)(3) — a specific written authorization is required before PHI (including photos) is used for marketing, separate from consent to treat",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.508"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "photo-001",
      "kind": "clinical",
      "materials": [
        "photography consent form (clinical-record scope)",
        "separate marketing/education-use authorization form",
        "practice management system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "patient",
        "caregiver",
        "dentist",
        "marketing",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Determine whether the photos are for the clinical record only, for patient education materials, or for marketing (website, social media, before/after gallery).\n\nWhy: The purpose determines which consent form applies; clinical-record consent alone does not authorize marketing use.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Identify the purpose of the photos before capture",
          "why": "The purpose determines which consent form applies; clinical-record consent alone does not authorize marketing use."
        },
        {
          "detail": "Can the patient give clinical-record photography consent on their own behalf?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "self-capacity",
              "label": "Patient is an adult with capacity to consent"
            },
            {
              "goto": "s8",
              "id": "guardian-capacity",
              "label": "Patient is a minor or otherwise unable to consent for themselves"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Can the patient give clinical-record photography consent on their own behalf?"
        },
        {
          "detail": "Confirm the patient has signed or verbally consented (per office policy) to clinical photos as part of the treatment record; document consent before the camera is used.\n\nWhy: Photos are PHI (HIPAA 45 CFR 164) and require the same consent posture as any other clinical record entry.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain standard clinical-record photography consent from the patient.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain standard clinical-record photography consent from the patient",
          "why": "Photos are PHI (HIPAA 45 CFR 164) and require the same consent posture as any other clinical record entry."
        },
        {
          "detail": "Did the patient (or parent/guardian) consent to clinical-record photography?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "consent-granted",
              "label": "Consent granted"
            },
            {
              "goto": "s9",
              "id": "consent-declined",
              "label": "Consent declined"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Did the patient (or parent/guardian) consent to clinical-record photography?"
        },
        {
          "detail": "Is any use beyond the clinical record intended?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "clinical-only",
              "label": "Clinical record only"
            },
            {
              "goto": "s10",
              "id": "beyond-clinical",
              "label": "Education or marketing use is intended"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Is any use beyond the clinical record intended?"
        },
        {
          "detail": "Record which consent(s) are on file (including whether obtained from the patient or a parent/guardian), the date, and the scope of use, in the patient's chart before or immediately after the photo session.\n\nRecord: consent type(s) obtained, decision-maker, date, scope of use, revocation status",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Document consent status in the chart"
        },
        {
          "detail": "Consent confirmed and documented; photography may proceed within scope",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Consent confirmed and documented; photography may proceed within scope"
        },
        {
          "detail": "Confirm the parent/guardian (or other authorized decision-maker) has signed or verbally consented, per office policy, to clinical photos of the minor or non-consenting patient as part of the treatment record; document consent before the camera is used.\n\nWhy: A minor or a patient who cannot consent for themselves needs the same clinical-record photography consent obtained from their parent, guardian, or authorized decision-maker instead.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain standard clinical-record photography consent from the parent or guardian.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "caregiver",
          "title": "Obtain standard clinical-record photography consent from the parent or guardian",
          "why": "A minor or a patient who cannot consent for themselves needs the same clinical-record photography consent obtained from their parent, guardian, or authorized decision-maker instead."
        },
        {
          "detail": "Chart that clinical photography consent was declined, by whom, and the date; do not capture any images, and continue treatment documentation by narrative chart notes only.\n\nRecord: consent declined, decision-maker, date, no photos taken",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Document the declined consent and proceed without photography"
        },
        {
          "detail": "Have the patient (or, for a minor or non-consenting patient, the parent/guardian who signed the clinical-record consent) sign a distinct authorization naming the specific use (website, social post, printed material), with an expiration or revocation option, before any image leaves the clinical record.\n\nWhy: 45 CFR 164.508(a)(3) requires a specific authorization for marketing use — clinical consent does not cover it, and a licensed provider should confirm scope before external use.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain a separate signed marketing/education-use authorization.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain a separate signed marketing/education-use authorization",
          "why": "45 CFR 164.508(a)(3) requires a specific authorization for marketing use — clinical consent does not cover it, and a licensed provider should confirm scope before external use."
        },
        {
          "detail": "Does the patient (or parent/guardian) want the option to revoke marketing use later?",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "revocable",
              "label": "Yes — note revocation right and process"
            },
            {
              "goto": "s12",
              "id": "no-revocation-note",
              "label": "No revocation discussion requested"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient (or parent/guardian) want the option to revoke marketing use later?"
        },
        {
          "detail": "Send marketing only the image(s) named in the authorization, with the approved use and any expiration date; do not send unauthorized images.\n\nWhy: Limiting what marketing receives keeps use inside the signed scope.",
          "id": "s12",
          "kind": "step",
          "role": "marketing",
          "title": "Hand the authorized image and its scope to marketing",
          "why": "Limiting what marketing receives keeps use inside the signed scope."
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Photography consent — clinical record versus education versus marketing use — Before any clinical photo is taken; marketing asks to use a before/after image.",
      "title": "Photography consent — clinical record versus education versus marketing use",
      "trigger": "Before any clinical photo is taken; marketing asks to use a before/after image",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "source": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC4086602/"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 8,
      "frequency": "per-use",
      "id": "photo-002",
      "kind": "clinical",
      "materials": [
        "clinical camera or phone with clinical-grade lens",
        "gray or neutral backdrop",
        "consistent lighting (ring flash or twin flash)",
        "tripod or stabilized handhold",
        "lip retractors (for the smile series if paired with intraoral)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Position the patient against a neutral backdrop with consistent lighting and a fixed camera distance so the series is comparable to future series.\n\nWhy: Consistent setup lets before/after and progress comparisons be visually valid rather than distorted by different lighting or distance.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Set up consistent backdrop, lighting and camera distance",
          "why": "Consistent setup lets before/after and progress comparisons be visually valid rather than distorted by different lighting or distance."
        },
        {
          "detail": "Patient faces the camera directly, head level, lips relaxed and closed (not smiling), natural head position.\n\nWhy: Rest position shows resting lip line and tooth display without a smile, a baseline esthetic reference.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Capture frontal view, lips at rest",
          "why": "Rest position shows resting lip line and tooth display without a smile, a baseline esthetic reference."
        },
        {
          "detail": "Same position as the rest view; ask the patient for a natural full smile showing the teeth.\n\nWhy: The full-smile view documents the smile line, buccal corridor and gingival display used in esthetic planning.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Capture frontal view, full smile",
          "why": "The full-smile view documents the smile line, buccal corridor and gingival display used in esthetic planning."
        },
        {
          "detail": "Patient turns 90 degrees so the camera captures a true lateral profile, lips at rest, ear visible as a reference point.\n\nWhy: Profile view documents facial and lip projection relevant to orthodontic and prosthodontic planning.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Capture right or left profile view",
          "why": "Profile view documents facial and lip projection relevant to orthodontic and prosthodontic planning."
        },
        {
          "detail": "Patient turns approximately 45 degrees from frontal; capture with a relaxed or smiling expression per the case need.\n\nWhy: The three-quarter view bridges frontal and profile, showing the smile arc from an angle patients see themselves at.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Capture three-quarter (45-degree) view",
          "why": "The three-quarter view bridges frontal and profile, showing the smile arc from an angle patients see themselves at."
        },
        {
          "detail": "Check each image immediately on the camera or phone screen before the patient leaves position; retake any image that is blurry, cropped incorrectly, or inconsistently lit.\n\nWhy: Catching a bad image before the patient leaves position avoids having to reschedule the whole series.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Review all four images for framing, focus and consistent lighting",
          "why": "Catching a bad image before the patient leaves position avoids having to reschedule the whole series."
        },
        {
          "detail": "Move to photo-007 (storage, tagging and PHI handling) to import and file the series into the chart.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the completed series to the storage and tagging protocol"
        },
        {
          "detail": "Extraoral series complete and ready for import",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Extraoral series complete and ready for import"
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Extraoral series — frontal rest, smile, profile, three-quarter — Records for an esthetic, orthodontic or comprehensive case.",
      "title": "Extraoral series — frontal rest, smile, profile, three-quarter",
      "trigger": "Records for an esthetic, orthodontic or comprehensive case",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "source": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC4086602/"
        },
        {
          "kind": "public_domain",
          "label": "CDC infection control for cameras, mirrors and retractors",
          "source": "CDC infection control for cameras, mirrors and retractors",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "photo-003",
      "kind": "clinical",
      "materials": [
        "clinical camera or phone with macro capability",
        "ring flash or twin flash",
        "lip and cheek retractors (adult and pediatric sizes)",
        "occlusal mirrors, warmed or anti-fog treated",
        "gauze to dry teeth and mirror between shots"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Choose adult or pediatric retractors based on the patient's mouth size, insert gently, and confirm the patient is comfortable before proceeding.\n\nWhy: A properly sized retractor pulls lips and cheeks clear of the field without causing pain or gagging.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Select and place appropriately sized retractors",
          "why": "A properly sized retractor pulls lips and cheeks clear of the field without causing pain or gagging."
        },
        {
          "detail": "With retractors holding lips and cheeks back, capture a straight-on view of both arches together in occlusion.\n\nWhy: The frontal retracted view is the baseline reference for midline, occlusion and anterior tooth condition.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Capture frontal retracted view, teeth in occlusion",
          "why": "The frontal retracted view is the baseline reference for midline, occlusion and anterior tooth condition."
        },
        {
          "detail": "Retract the right cheek and capture the right posterior teeth in occlusion from a 90-degree lateral angle.\n\nWhy: Buccal views document posterior occlusion and restorations not visible frontally.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Capture right buccal view",
          "why": "Buccal views document posterior occlusion and restorations not visible frontally."
        },
        {
          "detail": "Retract the left cheek and capture the left posterior teeth in occlusion from a 90-degree lateral angle.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Capture left buccal view"
        },
        {
          "detail": "Place a fog-free occlusal mirror against the upper arch, angle the camera to capture the full arch from the mirror reflection, dry teeth with gauze first if needed.\n\nWhy: A warmed or anti-fog mirror prevents condensation that would obscure the reflection.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Capture upper occlusal view using a warmed mirror",
          "why": "A warmed or anti-fog mirror prevents condensation that would obscure the reflection."
        },
        {
          "detail": "Repeat the mirror technique for the lower arch, capturing the full arch from the mirror reflection.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Capture lower occlusal view using a warmed mirror"
        },
        {
          "detail": "Check each image on-screen before removing retractors; retake any image with a fogged mirror, missing arch coverage, or motion blur.\n\nWhy: Catching a fogged or incomplete image before removing retractors avoids re-inserting them for a retake later.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Review all five images for fogging, focus and full-arch coverage",
          "why": "Catching a fogged or incomplete image before removing retractors avoids re-inserting them for a retake later."
        },
        {
          "detail": "Remove retractors gently, offer water, and ask if the patient's mouth or lip corners are sore.\n\nWhy: Retractors can cause minor lip-corner irritation; checking in supports patient comfort and catches any issue early.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Remove retractors and check patient comfort",
          "why": "Retractors can cause minor lip-corner irritation; checking in supports patient comfort and catches any issue early."
        },
        {
          "detail": "Move to photo-007 (storage, tagging and PHI handling) to import and file the series into the chart.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the completed series to the storage and tagging protocol"
        },
        {
          "detail": "Intraoral series complete and ready for import",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Intraoral series complete and ready for import"
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Intraoral series — frontal, right and left buccal, upper and lower occlusal, with retractors and mirrors — Records for any comprehensive, cosmetic or orthodontic case.",
      "title": "Intraoral series — frontal, right and left buccal, upper and lower occlusal, with retractors and mirrors",
      "trigger": "Records for any comprehensive, cosmetic or orthodontic case",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "source": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC4086602/"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 12,
      "frequency": "per-use",
      "id": "photo-004",
      "kind": "clinical",
      "materials": [
        "shade guide or reference tab matched to the target restoration material",
        "cross-polarizing filter for camera and flash (if available)",
        "gray card for white balance",
        "clinical camera with macro capability",
        "lab case-upload portal or secure file transfer"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Compare the reference tab to the adjacent natural teeth under consistent, color-corrected lighting (avoid direct colored overhead light) and select the closest match before photographing.\n\nWhy: Shade selection by eye under poor lighting is the most common source of a lab remake; get the visual match right before the camera is involved.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Select the shade reference tab under natural or color-corrected light",
          "why": "Shade selection by eye under poor lighting is the most common source of a lab remake; get the visual match right before the camera is involved."
        },
        {
          "detail": "Photograph or meter off a neutral gray card under the same lighting used for the patient shot, and set the camera's white balance accordingly.\n\nWhy: Incorrect white balance shifts the color the lab sees on-screen, defeating the purpose of a photographic shade record.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Set camera white balance using a gray card",
          "why": "Incorrect white balance shifts the color the lab sees on-screen, defeating the purpose of a photographic shade record."
        },
        {
          "detail": "Is cross-polarizing equipment available?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "polarized-yes",
              "label": "Cross-polarizing filters are available"
            },
            {
              "goto": "s10",
              "id": "polarized-no",
              "label": "No cross-polarizing equipment on hand"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is cross-polarizing equipment available?"
        },
        {
          "detail": "Attach the polarizing filter to both the flash and the lens, hold the reference tab directly adjacent to the target tooth, and capture the image.\n\nWhy: Cross-polarization removes surface glare, revealing true underlying tooth color and translucency the lab needs.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Capture shade photo with cross-polarizing filters on camera and flash",
          "why": "Cross-polarization removes surface glare, revealing true underlying tooth color and translucency the lab needs."
        },
        {
          "detail": "Confirm the reference tab and target tooth are both clearly visible, in focus, and not overexposed or underexposed; retake if not.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Review the image for correct tab placement and exposure"
        },
        {
          "detail": "Include the shade photo(s) with the written prescription and any digital scan in the case sent to the laboratory.\n\nWhy: A shade photo without the accompanying prescription context is not useful to a technician matching porcelain layering.",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Attach the shade photo(s) to the lab prescription and case upload",
          "why": "A shade photo without the accompanying prescription context is not useful to a technician matching porcelain layering."
        },
        {
          "detail": "Once the lab upload is confirmed, move to photo-007 (storage, tagging and PHI handling) to import the local copy into the chart and wipe the capture device.\n\nWhy: A shade photo sent to the lab still leaves a local copy on the capture device that must be filed and wiped like any other clinical image.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the local shade photo(s) to the storage and tagging protocol",
          "why": "A shade photo sent to the lab still leaves a local copy on the capture device that must be filed and wiped like any other clinical image."
        },
        {
          "detail": "Record the shade tab number/name and note that a reference photo was captured and sent with the case.\n\nRecord: selected shade reference, photo capture confirmation, case/lab reference number",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Document the selected shade and photo reference in the chart"
        },
        {
          "detail": "Shade photography complete and included with the lab case",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Shade photography complete and included with the lab case"
        },
        {
          "detail": "Hold the reference tab directly adjacent to the target tooth, angle the flash to reduce direct glare, and capture the image.\n\nWhy: Without polarization, careful flash angling is the next-best way to reduce a false-bright reading.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Capture shade photo without polarization, minimizing glare",
          "why": "Without polarization, careful flash angling is the next-best way to reduce a false-bright reading."
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Shade photography with reference tab, cross-polarization and lab upload — An indirect esthetic restoration is planned.",
      "title": "Shade photography with reference tab, cross-polarization and lab upload",
      "trigger": "An indirect esthetic restoration is planned",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "source": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC4086602/"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (photos are PHI; storage and disclosure) and 164.508 authorization for marketing use",
          "source": "HIPAA 45 CFR 164 (photos are PHI; storage and disclosure) and 164.508 authorization for marketing use",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "photo-005",
      "kind": "clinical",
      "materials": [
        "clinical camera or phone with macro capability",
        "millimeter scale marker or ruler",
        "consistent, well-lit examination setting",
        "chart documentation template for findings"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Examine the area, note location, size, color, texture and any patient-reported history (onset, pain, prior trauma) before photographing.\n\nWhy: A photo without a clinical description loses context a later reviewer would need.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify and clinically describe the lesion, injury or finding",
          "why": "A photo without a clinical description loses context a later reviewer would need."
        },
        {
          "detail": "Is abuse or neglect suspected as a cause?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-suspicion",
              "label": "No suspicion of abuse or neglect"
            },
            {
              "goto": "s9",
              "id": "suspicion",
              "label": "Abuse or neglect is suspected"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is abuse or neglect suspected as a cause?"
        },
        {
          "detail": "Place a millimeter scale or ruler adjacent to the finding so size is objectively measurable from the image, and capture at least one close-up and one wider context image.\n\nWhy: A scale reference lets anyone reviewing the photo later measure the finding without having re-examined the patient.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Photograph the finding with a scale marker included in frame",
          "why": "A scale reference lets anyone reviewing the photo later measure the finding without having re-examined the patient."
        },
        {
          "detail": "Take additional images from other angles or lighting if the finding is not fully visible in one shot.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Capture additional angles as needed"
        },
        {
          "detail": "Confirm the images clearly show the finding, the scale marker, and enough surrounding anatomy for context; retake if not adequate.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Review images for clarity and adequacy of documentation"
        },
        {
          "detail": "Chart the clinical description, note that photos were taken and filed, and — if applicable — document that a mandated report was made, to whom, and when.\n\nRecord: clinical description, photo reference, mandated-report confirmation and recipient if applicable",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document the finding, photos and any report made"
        },
        {
          "detail": "Move to photo-007 (storage, tagging and PHI handling) to import the scale-referenced finding photos into the chart, tag them, and wipe the capture device.\n\nWhy: These are the class's most legally sensitive images; an unmanaged local copy left on a camera or phone is an unacceptable PHI exposure for an evidentiary finding.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the finding photos to the storage and tagging protocol",
          "why": "These are the class's most legally sensitive images; an unmanaged local copy left on a camera or phone is an unacceptable PHI exposure for an evidentiary finding."
        },
        {
          "detail": "Finding documented with scale-referenced photos and required reporting complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Finding documented with scale-referenced photos and required reporting complete"
        },
        {
          "detail": "The examining dentist personally confirms that a report to the appropriate protective services authority will be made per state mandated-reporter law — this is the dentist's own non-delegable statutory duty, not discharged by asking compliance to handle it — and reports (or directs the report) before the end of the same business day per the practice's state-specific mandated-reporter timeline documented in the compliance binder; the compliance officer logs the report alongside (not instead of) photo documentation.\n\nWhy: Photo documentation supports a suspected-abuse finding but never substitutes for the legally required report; this gate exists so photography does not become the whole response.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist personally confirms and directs the mandated report before proceeding.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist personally confirms and directs the mandated report before proceeding",
          "why": "Photo documentation supports a suspected-abuse finding but never substitutes for the legally required report; this gate exists so photography does not become the whole response."
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Lesion, trauma or injury documentation photos with scale — A lesion, injury or suspected abuse finding must be documented.",
      "title": "Lesion, trauma or injury documentation photos with scale",
      "trigger": "A lesion, injury or suspected abuse finding must be documented",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC infection control for cameras, mirrors and retractors",
          "source": "CDC infection control for cameras, mirrors and retractors",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 6,
      "frequency": "per-shift",
      "id": "photo-006",
      "kind": "clinical",
      "materials": [
        "clinical camera or phone with macro lens",
        "spare charged battery or charging cable",
        "disposable barrier sleeves for camera/phone (where used)",
        "sterilized or high-level-disinfected mirrors and retractors",
        "equipment log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm the camera/phone has adequate battery charge and free storage before the session; swap in a charged battery or free storage if needed.\n\nWhy: A dead battery or full card mid-series forces an incomplete or delayed record.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Check camera or phone battery and storage space",
          "why": "A dead battery or full card mid-series forces an incomplete or delayed record."
        },
        {
          "detail": "Check that macro mode, flash/ring-light settings, resolution and white balance are set to the practice's standard clinical photography profile, not a setting left over from personal use.\n\nWhy: Inconsistent settings between sessions make progress photos hard to compare.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Verify camera settings match the standard clinical profile",
          "why": "Inconsistent settings between sessions make progress photos hard to compare."
        },
        {
          "detail": "Is the mirror/retractor set single-use disposable or reusable?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "single-use",
              "label": "Single-use disposable items"
            },
            {
              "goto": "s8",
              "id": "reusable",
              "label": "Reusable sterilizable items"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the mirror/retractor set single-use disposable or reusable?"
        },
        {
          "detail": "Check the packaging is sealed and within its expiration or use-by date before opening for the session.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm single-use items are in sealed, unexpired packaging"
        },
        {
          "detail": "If the camera or phone will be held close to or touched by the patient, apply a disposable barrier sleeve per the practice's barrier policy.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Apply a barrier sleeve to the camera/phone if used intraorally close to the patient"
        },
        {
          "detail": "Note in the equipment log that the pre-session check was completed, including reprocessing confirmation for reusable items.\n\nRecord: date/shift, battery/storage check, reprocessing or single-use confirmation, barrier use",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Log the equipment check"
        },
        {
          "detail": "Camera and equipment ready for a clinically safe photo session",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Camera and equipment ready for a clinically safe photo session"
        },
        {
          "detail": "Check the sterilization indicator or disinfection log confirms the mirrors and retractors being used were reprocessed per the practice's infection control protocol before this session.\n\nWhy: Photography equipment that touches the mouth carries the same cross-contamination risk as any other intraoral instrument (CDC dental infection control guidance).",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm reusable items show current sterilization or high-level disinfection",
          "why": "Photography equipment that touches the mouth carries the same cross-contamination risk as any other intraoral instrument (CDC dental infection control guidance)."
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Camera setup — settings, mirror and retractor reprocessing, barrier use — The start of a photo session or the weekly equipment check.",
      "title": "Camera setup — settings, mirror and retractor reprocessing, barrier use",
      "trigger": "The start of a photo session or the weekly equipment check",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164 (photos are PHI; storage and disclosure) and 164.508 authorization for marketing use",
          "source": "HIPAA 45 CFR 164 (photos are PHI; storage and disclosure) and 164.508 authorization for marketing use",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.312 — technical safeguards (encryption, access control) for electronic PHI",
          "source": "45 CFR 164.312 — technical safeguards (encryption, access control) for electronic PHI",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C/section-164.312"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "photo-007",
      "kind": "clinical",
      "materials": [
        "practice management system or imaging module with encrypted storage",
        "secure transfer cable or encrypted transfer method",
        "device wipe procedure documentation"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Transfer the session's photos directly into the practice management system's imaging module or encrypted storage using a secure connection (cable or approved secure app), not a personal cloud service.\n\nWhy: Photos are PHI; routing them through an unencrypted or personal cloud path (45 CFR 164.312 technical safeguards) creates an unmanaged disclosure risk.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Import photos from the capture device into the encrypted practice system",
          "why": "Photos are PHI; routing them through an unencrypted or personal cloud path (45 CFR 164.312 technical safeguards) creates an unmanaged disclosure risk."
        },
        {
          "detail": "Attach each imported image to the correct patient chart and the specific visit/date, using the practice's tagging taxonomy (e.g. extraoral, intraoral, shade, lesion).\n\nWhy: An untagged or mis-tagged image is effectively lost PHI — it exists but cannot be found or matched to the right patient later.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Tag each image to the correct patient and visit",
          "why": "An untagged or mis-tagged image is effectively lost PHI — it exists but cannot be found or matched to the right patient later."
        },
        {
          "detail": "Was a personal phone used for capture (the non-default exception) rather than a practice-owned device?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "practice-device",
              "label": "Practice-owned device only"
            },
            {
              "goto": "s9",
              "id": "personal-device",
              "label": "A personal phone was used (exception — requires compliance pre-approval)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Was a personal phone used for capture (the non-default exception) rather than a practice-owned device?"
        },
        {
          "detail": "Open the patient's chart and confirm every expected image from the session is present, correctly tagged, and displays without error.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Verify the images imported successfully and are viewable in the chart"
        },
        {
          "detail": "Once import is verified, delete the session's photos from the camera or phone's local storage (and empty any device trash/recently-deleted folder).\n\nWhy: Leaving a verified-imported copy on the capture device creates a second, less-controlled copy of PHI with no benefit once the chart copy exists.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Delete the images from the capture device",
          "why": "Leaving a verified-imported copy on the capture device creates a second, less-controlled copy of PHI with no benefit once the chart copy exists."
        },
        {
          "detail": "Did the import or wipe encounter a technical problem?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-issue",
              "label": "Import and wipe completed without issue"
            },
            {
              "goto": "s10",
              "id": "issue",
              "label": "A technical problem occurred (failed import, device won't wipe, sync error)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Did the import or wipe encounter a technical problem?"
        },
        {
          "detail": "Note in the equipment or PHI-handling log that the session's images were imported, tagged, verified, and the capture device was wiped (or the IT ticket reference if unresolved).\n\nRecord: session date, patient/visit tag confirmation, device wipe confirmation, IT ticket reference if applicable",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the import and device-wipe confirmation"
        },
        {
          "detail": "Photos securely stored, tagged and removed from the capture device",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Photos securely stored, tagged and removed from the capture device"
        },
        {
          "detail": "Confirm personal-device photo capture is within the practice's device policy and that staff commit to deleting the images from the personal device immediately once import is verified (the actual deletion happens at step-wipe-device, next in this flow).\n\nWhy: PHI left on a personal device outside practice control is an unmanaged disclosure risk the moment the device is lost, sold or synced to a personal cloud account.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm personal-device use is permitted and wipe is completed.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm personal-device use is permitted and wipe is completed",
          "why": "PHI left on a personal device outside practice control is an unmanaged disclosure risk the moment the device is lost, sold or synced to a personal cloud account."
        },
        {
          "detail": "Report the specific device, error and affected patient session to the IT vendor; do not leave unresolved PHI on a device unattended.",
          "id": "s10",
          "kind": "step",
          "role": "it-vendor",
          "title": "Escalate the technical problem to IT support"
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Photo import, chart tagging, encrypted storage and device wipe — Photos exist on a camera or phone after a session.",
      "title": "Photo import, chart tagging, encrypted storage and device wipe",
      "trigger": "Photos exist on a camera or phone after a session",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "source": "Standardized extraoral and intraoral clinical photography view series (facial frontal rest/smile, profile, three-quarter; retracted frontal, right/left buccal, upper/lower occlusal) as documented in open-access, peer-reviewed dental literature on standardized dental photography, e.g. Ahmad I, \"Digital Dental Photography: A Contemporary Revolution,\" Journal of Conservative Dentistry (PubMed Central open access) — a generically taught view set, not a proprietary system",
          "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC4086602/"
        }
      ],
      "class": "clinical-photography",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "photo-008",
      "kind": "clinical",
      "materials": [
        "clinical camera or phone with macro capability",
        "prior baseline photo series for reference",
        "same retractors, mirrors, backdrop and lighting used at baseline where possible"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Open the patient's original baseline series (extraoral and/or intraoral) on-screen for reference before positioning the patient for new photos.\n\nWhy: Matching the original angles, distance and lighting is what makes a before/after comparison meaningful rather than misleading.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Pull up the baseline photo series before the new session",
          "why": "Matching the original angles, distance and lighting is what makes a before/after comparison meaningful rather than misleading."
        },
        {
          "detail": "Set up the same or closest-available backdrop, lighting and camera distance used in the baseline series.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Match backdrop, lighting and camera distance to the baseline"
        },
        {
          "detail": "For each view in the original series (e.g. frontal rest, frontal smile, profile, intraoral frontal, buccal, occlusal), capture the matching view now, referencing the baseline image on-screen for angle and framing.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Capture each view present in the baseline series"
        },
        {
          "detail": "Place the new and baseline images side by side and confirm the angle, distance and lighting are close enough for a fair visual comparison; retake any view that doesn't match well.\n\nWhy: A poorly matched progress photo can make treatment look better or worse than it actually is, which misleads both the chart and the patient conversation.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Compare new images against baseline for framing consistency",
          "why": "A poorly matched progress photo can make treatment look better or worse than it actually is, which misleads both the chart and the patient conversation."
        },
        {
          "detail": "Move to photo-007 (storage, tagging and PHI handling) to import and file the series into the chart, tagged as progress or post-treatment with the milestone noted.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the completed series to the storage and tagging protocol"
        },
        {
          "detail": "Note in the chart which treatment milestone this series documents and confirm it has been tagged for comparison against baseline.\n\nRecord: treatment milestone, series tag, baseline reference",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Document the milestone and series comparison"
        },
        {
          "detail": "Progress or post-treatment series complete and comparable to baseline",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Progress or post-treatment series complete and comparable to baseline"
        }
      ],
      "subclass": "clinical-dental-photography",
      "summary": "Progress and post-treatment photo series matching baseline views — A mid-treatment check or case completion.",
      "title": "Progress and post-treatment photo series matching baseline views",
      "trigger": "A mid-treatment check or case completion",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Education Code §49452.8 — kindergarten / first-grade oral health assessment requirement and form",
          "source": "California Education Code §49452.8 — kindergarten / first-grade oral health assessment requirement and form",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=EDC&sectionNum=49452.8"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary — the form releases only what the school requires",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary — the form releases only what the school requires",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "plf-001",
      "kind": "operational",
      "materials": [
        "blank school form",
        "patient chart",
        "pen",
        "copier or scanner"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Front desk logs the form, the requesting school, and the deadline; confirms the child is an active patient of record and that the adult presenting the request is the child's parent or legal guardian of record.\n\nWhy: A deadline missed at intake is the most common reason these forms come back late.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the school form request",
          "why": "A deadline missed at intake is the most common reason these forms come back late."
        },
        {
          "detail": "Assistant pulls the chart and checks the date of the most recent completed oral exam against the school's required window.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Pull the chart and check exam currency"
        },
        {
          "detail": "Is a current exam already on file?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "current",
              "label": "Exam on file is within the required window"
            },
            {
              "goto": "s9",
              "id": "needed",
              "label": "No current exam — one must be performed first"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is a current exam already on file?"
        },
        {
          "detail": "Assistant transcribes the exam findings onto the school form using only the fields the form asks for, nothing extra.\n\nWhy: HIPAA minimum necessary — a school form is not an invitation to attach the whole record.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Fill in the form from the chart",
          "why": "HIPAA minimum necessary — a school form is not an invitation to attach the whole record."
        },
        {
          "detail": "Dentist reviews the completed form against the chart and signs it personally before it leaves the office; nothing is pre-signed or stamped.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the form personally.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the form personally"
        },
        {
          "detail": "Front desk notes in the chart that the form was completed and signed, with the date and the recipient (school).\n\nRecord: Date, form type, and recipient noted in the patient's chart; a copy is retained per the office's retention schedule.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the form in the chart"
        },
        {
          "detail": "Front desk hands the original to the parent or guardian and keeps the office copy filed with the chart.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Give the form to the parent or guardian"
        },
        {
          "detail": "Form issued",
          "id": "s8",
          "kind": "step",
          "title": "Form issued"
        },
        {
          "detail": "Front desk books the child for an exam before the school deadline, flagging the visit as form-driven.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the exam needed to complete the form"
        },
        {
          "detail": "Dentist performs the exam required to answer the form's clinical questions and records findings in the chart.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the oral health exam"
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "School oral health assessment or school dental form completion — A parent brings a school-entry oral health assessment form (CA kindergarten/first-grade requirement) or a school sports form.",
      "title": "School oral health assessment or school dental form completion",
      "trigger": "A parent brings a school-entry oral health assessment form (CA kindergarten/first-grade requirement) or a school sports form",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary — an excuse note states only that an appointment occurred, not the diagnosis",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary — an excuse note states only that an appointment occurred, not the diagnosis",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "For excuse notes — no vendor form reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for excuse notes — no vendor form reproduced"
          },
          "source": "For excuse notes — no vendor form reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 8,
      "frequency": "as-needed",
      "id": "plf-002",
      "kind": "operational",
      "materials": [
        "excuse note template",
        "patient chart"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Front desk confirms the patient's identity and that the appointment shown on the note actually occurred.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the request"
        },
        {
          "detail": "Front desk drafts a brief note stating the patient was seen at the office on the visit date, with no diagnosis or treatment detail.\n\nWhy: Minimum necessary — an employer or school does not need clinical detail to accept an excuse.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Draft the note",
          "why": "Minimum necessary — an employer or school does not need clinical detail to accept an excuse."
        },
        {
          "detail": "Does the note need to state a recovery or rest period?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "recovery",
              "label": "Procedure requires a stated recovery period (e.g., extraction)"
            },
            {
              "goto": "s5",
              "id": "no-recovery",
              "label": "Routine visit, no recovery period needed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the note need to state a recovery or rest period?"
        },
        {
          "detail": "Dentist states the recommended rest or recovery period based on the procedure performed, in plain language.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist specifies the recovery period"
        },
        {
          "detail": "Dentist reviews the note's wording for accuracy and signs or initials it personally before it is handed over.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs"
        },
        {
          "detail": "Front desk notes the date issued and the recipient (employer or school) in the chart's contact log.\n\nRecord: Date, note type, and recipient logged in the chart.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the note in the chart"
        },
        {
          "detail": "Front desk gives the signed note directly to the patient or authorized caregiver.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand the note to the patient"
        },
        {
          "detail": "Note issued",
          "id": "s8",
          "kind": "step",
          "title": "Note issued"
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "Work or school excuse note after an appointment — A patient asks for a note excusing absence for the visit or recovery period.",
      "title": "Work or school excuse note after an appointment",
      "trigger": "A patient asks for a note excusing absence for the visit or recovery period",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary and 164.508 authorization for disclosures — the letter releases clinical findings relevant to the surgery only",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary and 164.508 authorization for disclosures — the letter releases clinical findings relevant to the surgery only",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "For a pre-surgical dental clearance letter — no vendor form reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a pre-surgical dental clearance letter — no vendor form reproduced"
          },
          "source": "For a pre-surgical dental clearance letter — no vendor form reproduced — Practice policy — no published authority governs this step."
        },
        {
          "kind": "open_standard",
          "label": "AAOMS MRONJ position paper (open) — completing needed extractions/periodontal treatment before starting antiresorptive therapy reduces MRONJ risk",
          "source": "AAOMS MRONJ position paper (open) — completing needed extractions/periodontal treatment before starting antiresorptive therapy reduces MRONJ risk",
          "url": "https://www.aaoms.org/practice-resources/clinical-resources/medication-related-osteonecrosis-of-the-jaw/"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "plf-003",
      "kind": "operational",
      "materials": [
        "clearance request fax/letter",
        "patient chart and radiographs",
        "clearance letter template",
        "fax or secure send"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Front desk logs the requesting physician's office, the surgery or therapy date, and the deadline, then flags the clinical team same day.\n\nWhy: These requests are time-critical against a surgery date the office does not control.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the clearance request and deadline",
          "why": "These requests are time-critical against a surgery date the office does not control."
        },
        {
          "detail": "Dentist reviews the chart and radiographs for anything relevant to the physician's specific request (e.g., active infection before a cardiac valve or joint procedure).",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Review chart and radiograph history"
        },
        {
          "detail": "Dentist matches the request to the relevant named scenario: for an antiresorptive (bisphosphonate/denosumab) start, note whether needed extractions or periodontal treatment should be completed first to reduce MRONJ risk per current guidance; for a cardiac valve or prosthetic joint request, note the specific procedure and the exact prophylaxis question the physician asked. This determines what the focused exam below must confirm.\n\nWhy: The clearance letter is for a named high-stakes scenario, not a generic checkup — the exam and letter need to answer the scenario's specific clinical question, not just find or rule out disease in general.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check the physician's request against known scenario-specific considerations",
          "why": "The clearance letter is for a named high-stakes scenario, not a generic checkup — the exam and letter need to answer the scenario's specific clinical question, not just find or rule out disease in general."
        },
        {
          "detail": "Is a current exam sufficient to answer the physician's request?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "sufficient",
              "label": "Current exam and imaging are sufficient"
            },
            {
              "goto": "s10",
              "id": "insufficient",
              "label": "An updated exam is needed before clearance can be assessed"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a current exam sufficient to answer the physician's request?"
        },
        {
          "detail": "Front desk drafts the letter stating the relevant findings and the clearance status (cleared, or pending treatment) using minimum necessary detail.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Draft the clearance letter"
        },
        {
          "detail": "Dentist personally reviews the letter's clinical statement for accuracy and signs it before it is sent; a clearance letter is never sent unsigned or on a staff member's authority.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the clearance letter personally.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the clearance letter personally"
        },
        {
          "detail": "Front desk logs a copy of the sent letter, the date, and the recipient physician's office in the chart.\n\nRecord: Copy of letter, date sent, and recipient logged in the chart.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the letter in the chart"
        },
        {
          "detail": "Front desk faxes or securely sends the letter to the requesting physician's office ahead of the surgery deadline.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the letter by the deadline"
        },
        {
          "detail": "Clearance letter sent",
          "id": "s9",
          "kind": "step",
          "title": "Clearance letter sent"
        },
        {
          "detail": "Front desk books an urgent exam appointment ahead of the surgery deadline.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule an urgent exam before the deadline"
        },
        {
          "detail": "Dentist examines for active infection or disease relevant to the physician's request and records findings.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the focused exam"
        },
        {
          "detail": "Does the patient need treatment before clearance can be given?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "clear",
              "label": "No active disease found — clearance can be issued"
            },
            {
              "goto": "s13",
              "id": "treatment-needed",
              "label": "Active infection or disease found — treatment needed first"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient need treatment before clearance can be given?"
        },
        {
          "detail": "Dentist outlines the treatment needed before clearance can be given and its expected timeline against the surgery date.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Outline the required treatment and its timeline"
        },
        {
          "detail": "Insurance coordinator contacts the requesting physician's office to flag the needed treatment and its timeline against the surgery date.",
          "id": "s14",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Notify the physician's office of the delay"
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "Pre-surgical dental clearance letter requested by a physician (cardiac valve, transplant, joint, radiation, antiresorptive start) — A physician's office faxes a dental clearance request before a patient's surgery or therapy.",
      "title": "Pre-surgical dental clearance letter requested by a physician (cardiac valve, transplant, joint, radiation, antiresorptive start)",
      "trigger": "A physician's office faxes a dental clearance request before a patient's surgery or therapy",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FMLA 29 CFR 825.306–825.308 — content and timing of health-care-provider certification",
          "source": "FMLA 29 CFR 825.306–825.308 — content and timing of health-care-provider certification",
          "url": "https://www.ecfr.gov/current/title-29/part-825"
        },
        {
          "kind": "statute",
          "label": "California Unemployment Insurance Code §2708 — State Disability Insurance practitioner certification within scope of practice",
          "source": "California Unemployment Insurance Code §2708 — State Disability Insurance practitioner certification within scope of practice",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=UIC&sectionNum=2708"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.508 authorization for disclosures to employers and insurers",
          "source": "HIPAA 45 CFR 164.508 authorization for disclosures to employers and insurers",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "plf-004",
      "kind": "operational",
      "materials": [
        "disability/FMLA/insurer form",
        "patient chart",
        "patient's disclosure authorization"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Front desk logs the form type, requesting party, and the certification deadline (FMLA certifications carry a regulatory response window).",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the form and its deadline"
        },
        {
          "detail": "Is this request within the dentist's scope of practice?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "in-scope",
              "label": "Request concerns a dental condition or treatment within scope"
            },
            {
              "goto": "s9",
              "id": "out-of-scope",
              "label": "Request concerns a condition outside dental scope of practice"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this request within the dentist's scope of practice?"
        },
        {
          "detail": "Dentist completes the clinical sections using objective exam findings and functional limitations tied to dental treatment only.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the clinical sections"
        },
        {
          "detail": "Billing confirms the patient's signed disclosure authorization is on file before the form leaves the office and cross-references any billing codes the form asks for.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Confirm authorization and billing cross-reference"
        },
        {
          "detail": "Dentist reviews the completed form for accuracy and signs it personally before it leaves the office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the completed form personally.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the completed form personally"
        },
        {
          "detail": "Front desk logs whether the form was completed and sent, or referred out, with the date and recipient.\n\nRecord: Form disposition (completed/referred), date, and recipient logged in the chart.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the form's disposition"
        },
        {
          "detail": "Front desk returns the completed form to the patient or submits it directly per the requesting party's instructions, ahead of the deadline.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Return the form by the deadline"
        },
        {
          "detail": "Form completed or referred",
          "id": "s8",
          "kind": "step",
          "title": "Form completed or referred"
        },
        {
          "detail": "Front desk informs the patient the form must be completed by a provider within the relevant scope of practice and documents the referral.\n\nWhy: A practitioner certification outside scope of practice is not valid and exposes both patient and practice.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Refer the patient to the appropriate provider",
          "why": "A practitioner certification outside scope of practice is not valid and exposes both patient and practice."
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "Disability, family-leave or insurer attending-provider form completion — A patient submits a disability, leave or accident-insurance form for the dentist to complete.",
      "title": "Disability, family-leave or insurer attending-provider form completion",
      "trigger": "A patient submits a disability, leave or accident-insurance form for the dentist to complete",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "IRS Publication 502 — eligible medical and dental expenses; letter-of-medical-necessity conventions for HSA/FSA administrators",
          "source": "IRS Publication 502 — eligible medical and dental expenses; letter-of-medical-necessity conventions for HSA/FSA administrators",
          "url": "https://www.irs.gov/publications/p502"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary — the letter states the condition and treatment, not the full chart",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary — the letter states the condition and treatment, not the full chart",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "plf-005",
      "kind": "operational",
      "materials": [
        "letter of medical necessity template",
        "patient chart and treatment plan",
        "IRS Publication 502 eligible-expense reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "dentist",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Treatment coordinator confirms the procedure or treatment plan is already documented in the chart before drafting begins.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Take the request"
        },
        {
          "detail": "Is the expense a clearly eligible medical/dental expense?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "eligible",
              "label": "Clearly eligible per IRS Publication 502 conventions"
            },
            {
              "goto": "s10",
              "id": "unclear",
              "label": "Eligibility or administrator requirements are unclear"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "Is the expense a clearly eligible medical/dental expense?"
        },
        {
          "detail": "Treatment coordinator drafts the letter stating the condition, the treatment prescribed, and the medical-necessity rationale, using minimum necessary detail.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Draft the letter"
        },
        {
          "detail": "Dentist reviews the drafted rationale for clinical accuracy before signing.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews clinical accuracy"
        },
        {
          "detail": "Dentist personally signs the letter attesting to medical necessity; the letter is never sent unsigned.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the letter personally.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the letter personally"
        },
        {
          "detail": "Billing logs that the letter was issued, the date, and the recipient (patient or administrator) in the billing notes.\n\nRecord: Letter issuance date and recipient logged in billing notes.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Log the letter"
        },
        {
          "detail": "Billing confirms the patient's signed authorization for release of the letter to the third-party administrator or payer is on file before the letter leaves the office.\n\nWhy: The letter discloses diagnosis and treatment detail to a third party — that disclosure needs a signed authorization on file, not just a verbal request.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Confirm signed disclosure authorization is on file",
          "why": "The letter discloses diagnosis and treatment detail to a third party — that disclosure needs a signed authorization on file, not just a verbal request."
        },
        {
          "detail": "Treatment coordinator gives the letter to the patient or submits it to the administrator per the patient's authorization.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Release the letter"
        },
        {
          "detail": "Letter issued",
          "id": "s9",
          "kind": "step",
          "title": "Letter issued"
        },
        {
          "detail": "Billing researches the specific FSA/HSA administrator's or payer's letter-content requirements before drafting.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Research administrator requirements"
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "Letter of medical necessity for HSA/FSA reimbursement or a medical payer — A patient asks for a letter to justify a dental expense to a flexible-spending administrator or medical plan.",
      "title": "Letter of medical necessity for HSA/FSA reimbursement or a medical payer",
      "trigger": "A patient asks for a letter to justify a dental expense to a flexible-spending administrator or medical plan",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary — the letter states treatment status and recommended accommodation, not full clinical detail",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary — the letter states treatment status and recommended accommodation, not full clinical detail",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "For a jury-duty/travel-fitness letter — no vendor form reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a jury-duty/travel-fitness letter — no vendor form reproduced"
          },
          "source": "For a jury-duty/travel-fitness letter — no vendor form reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 12,
      "frequency": "as-needed",
      "id": "plf-006",
      "kind": "operational",
      "materials": [
        "letter template",
        "patient chart"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Front desk confirms the patient's current treatment phase in the chart before anything is drafted.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the request"
        },
        {
          "detail": "Does the patient's clinical status support the requested statement?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "supported",
              "label": "Clinical status supports the requested statement (e.g., recent surgery, active recovery)"
            },
            {
              "goto": "s8",
              "id": "not-supported",
              "label": "Clinical status does not support the requested statement"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the patient's clinical status support the requested statement?"
        },
        {
          "detail": "Front desk drafts a brief factual letter stating treatment status and the recommended accommodation, using minimum necessary detail.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Draft the letter"
        },
        {
          "detail": "Dentist reviews the letter's clinical accuracy and signs it personally before release.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs"
        },
        {
          "detail": "Front desk logs the date issued and the recipient (court, employer, or travel authority) in the chart.\n\nRecord: Letter issuance date and recipient logged in the chart.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the issued letter"
        },
        {
          "detail": "Front desk hands the signed letter directly to the patient.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Give the letter to the patient"
        },
        {
          "detail": "Request resolved (letter issued or declined)",
          "id": "s7",
          "kind": "step",
          "title": "Request resolved (letter issued or declined)"
        },
        {
          "detail": "Dentist explains that the current clinical status doesn't support the requested statement and offers alternative accurate wording if any applies.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the clinical facts to the patient"
        },
        {
          "detail": "Front desk logs the request, the reason it was declined, and any alternative offered.\n\nRecord: Declined request and reasoning logged in the chart.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the declined request"
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "Jury duty, court or travel fitness letter for a patient in active treatment — A patient in surgery recovery or active treatment asks for a letter to defer jury duty, a court date or to fly.",
      "title": "Jury duty, court or travel fitness letter for a patient in active treatment",
      "trigger": "A patient in surgery recovery or active treatment asks for a letter to defer jury duty, a court date or to fly",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Section 1557 / Title VI language access — 45 CFR Part 92 (meaningful access for limited-English-proficient patients, translated vital documents where thresholds apply)",
          "source": "Section 1557 / Title VI language access — 45 CFR Part 92 (meaningful access for limited-English-proficient patients, translated vital documents where thresholds apply)",
          "url": "https://www.ecfr.gov/current/title-45/part-92"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary applies equally to translated materials",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary applies equally to translated materials",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        }
      ],
      "class": "front-office-operations",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "plf-007",
      "kind": "operational",
      "materials": [
        "English source document (versioned)",
        "translation service or bilingual reviewer",
        "back-translation reviewer",
        "document version log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Office manager identifies a consent or instruction sheet needed in a served language, or notes that the English source was edited and translations are now stale.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the translation need"
        },
        {
          "detail": "Compliance officer locks the current English source text, assigns it a version number and date, before any translation begins.\n\nWhy: A moving source is what causes translations to drift out of sync silently.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Lock the English source as the version of record",
          "why": "A moving source is what causes translations to drift out of sync silently."
        },
        {
          "detail": "Front desk or compliance officer commissions the translation of the locked source from a qualified bilingual reviewer or translation service.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Commission the translation"
        },
        {
          "detail": "Compliance officer commissions an independent back-translation of the translated document into English, done by someone other than the original translator.\n\nWhy: Title VI meaningful-access practice — an independent back-translation is how meaning drift gets caught before a patient signs the wrong thing.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Commission an independent back-translation",
          "why": "Title VI meaningful-access practice — an independent back-translation is how meaning drift gets caught before a patient signs the wrong thing."
        },
        {
          "detail": "Does the back-translation match the source's meaning and legal content?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "match",
              "label": "Back-translation matches the source"
            },
            {
              "goto": "s10",
              "id": "mismatch",
              "label": "Back-translation reveals a meaning discrepancy"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the back-translation match the source's meaning and legal content?"
        },
        {
          "detail": "Compliance officer signs off that the translated document is accurate and approved for patient use before it replaces the prior version.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before publication.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before publication"
        },
        {
          "detail": "Front desk replaces the prior version in the patient materials, notes the effective date, and archives the superseded version.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Publish the new version"
        },
        {
          "detail": "Office manager logs the source version, translator, back-translation reviewer, and effective date in the compliance file.\n\nRecord: Version history entry: source version, translator, back-translation reviewer, effective date.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the version history"
        },
        {
          "detail": "Translated document published",
          "id": "s9",
          "kind": "step",
          "title": "Translated document published"
        },
        {
          "detail": "Compliance officer sends the specific discrepancies back to the original translator for correction and re-submission.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Send discrepancies back for correction"
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "Translated consent forms and patient materials: source control and back-translation — A consent or instruction sheet is needed in a language the office serves regularly, or a translated form is edited.",
      "title": "Translated consent forms and patient materials: source control and back-translation",
      "trigger": "A consent or instruction sheet is needed in a language the office serves regularly, or a translated form is edited",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary — a superbill lists procedure codes, dates, and fees for the patient's own submission",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary — a superbill lists procedure codes, dates, and fees for the patient's own submission",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "For a superbill / itemized statement template — no vendor form reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a superbill / itemized statement template — no vendor form reproduced"
          },
          "source": "For a superbill / itemized statement template — no vendor form reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "plf-008",
      "kind": "operational",
      "materials": [
        "billing ledger",
        "superbill template",
        "procedure and diagnosis code reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Front desk confirms the patient's identity and which visit(s) the superbill should cover.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the request"
        },
        {
          "detail": "Billing verifies all procedure codes, dates of service, fees, and provider identifiers are accurate and complete in the ledger for the visit.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Verify the ledger"
        },
        {
          "detail": "Billing generates the itemized statement using minimum necessary format: procedure codes, dates, fees, and diagnosis codes only if the payer requires them.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Generate the statement"
        },
        {
          "detail": "Are there pending or unposted charges for the visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "complete",
              "label": "All charges for the visit are posted"
            },
            {
              "goto": "s8",
              "id": "pending",
              "label": "Some charges are still pending or unposted"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "billing",
          "title": "Are there pending or unposted charges for the visit?"
        },
        {
          "detail": "Front desk gives or sends the statement to the patient by the patient's stated preferred delivery method.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Release the statement"
        },
        {
          "detail": "Billing logs that a superbill was issued, the date, and the visit(s) it covers.\n\nRecord: Superbill issuance date and covered visit(s) logged in billing notes.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Log the issuance"
        },
        {
          "detail": "Superbill issued",
          "id": "s7",
          "kind": "step",
          "title": "Superbill issued"
        },
        {
          "detail": "Billing holds the superbill until the pending charges post and notifies the patient of the short delay.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Hold and notify"
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "Superbill or itemized statement for a patient's own insurance submission — An out-of-network or self-pay patient asks for a superbill to file their own claim.",
      "title": "Superbill or itemized statement for a patient's own insurance submission",
      "trigger": "An out-of-network or self-pay patient asks for a superbill to file their own claim",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(b) minimum necessary; 164.508 authorization for disclosures to employers, schools and insurers; 164.524 right of access",
          "source": "HIPAA 45 CFR 164.502(b) minimum necessary; 164.508 authorization for disclosures to employers, schools and insurers; 164.524 right of access",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "regulation",
          "label": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent required before automated texts/calls, opt-out honoring",
          "source": "TCPA 47 U.S.C. §227 + 47 CFR 64.1200 — prior express consent required before automated texts/calls, opt-out honoring",
          "url": "https://www.ecfr.gov/current/title-47/section-64.1200"
        },
        {
          "kind": "regulation",
          "label": "45 CFR 164.520 — notice of privacy practices must be provided at first service delivery and a good-faith acknowledgment of receipt obtained",
          "source": "45 CFR 164.520 — notice of privacy practices must be provided at first service delivery and a good-faith acknowledgment of receipt obtained",
          "url": "https://www.ecfr.gov/current/title-45/section-164.520"
        },
        {
          "kind": "generic",
          "label": "For welcome-packet wording, financial-policy and cancellation-policy language — no vendor or consultancy template reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for welcome-packet wording, financial-policy and cancellation-policy language — no vendor or consultancy template reproduced"
          },
          "source": "For welcome-packet wording, financial-policy and cancellation-policy language — no vendor or consultancy template reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "plf-009",
      "kind": "operational",
      "materials": [
        "Welcome packet (practice overview, office hours, contact methods)",
        "Financial policy document (payment expectations, insurance handling, financing options)",
        "Cancellation and no-show policy document",
        "Communication consent form (text/email/phone preferences, TCPA opt-in language)",
        "HIPAA notice of privacy practices acknowledgment",
        "New-patient intake and health history forms",
        "Patient portal or online-form-system access instructions",
        "Signature capture method (paper or e-signature)",
        "Acknowledgment log (paper file or practice-management system)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm whether this run is (a) a brand-new patient just booked, needing the full welcome packet, or (b) an existing-patient population that must re-acknowledge a changed policy (fee schedule, cancellation window, communication consent). The packet contents and recipient list differ.\n\nWhy: A new-patient packet and a policy-change re-acknowledgment share the same forms but different scope and urgency; misidentifying the trigger sends the wrong document set.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the trigger: new booking or policy change",
          "why": "A new-patient packet and a policy-change re-acknowledgment share the same forms but different scope and urgency; misidentifying the trigger sends the wrong document set."
        },
        {
          "detail": "Confirm the current versions of: practice welcome overview, financial policy, cancellation/no-show policy, communication consent form, HIPAA notice of privacy practices, intake and health-history forms, portal access instructions.\n\nWhy: Sending an outdated fee schedule or an old cancellation window creates a dispute the practice cannot enforce later.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "Welcome packet",
            "Financial policy document",
            "Cancellation and no-show policy document",
            "Communication consent form",
            "HIPAA notice of privacy practices acknowledgment",
            "New-patient intake and health history forms"
          ],
          "role": "office-manager",
          "title": "Assemble the packet",
          "why": "Sending an outdated fee schedule or an old cancellation window creates a dispute the practice cannot enforce later."
        },
        {
          "detail": "Attach the current notice of privacy practices and a separate acknowledgment-of-receipt line for the patient to sign. Federal rule requires a good-faith effort to obtain this acknowledgment at first service delivery.\n\nWhy: 45 CFR 164.520 requires the notice be provided and a good-faith acknowledgment attempted; skipping it is a documented compliance gap even if care is not affected.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Include the HIPAA notice of privacy practices",
          "why": "45 CFR 164.520 requires the notice be provided and a good-faith acknowledgment attempted; skipping it is a documented compliance gap even if care is not affected."
        },
        {
          "detail": "Branch on the trigger identified at the start of the run.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "new-patient",
              "label": "New patient, first packet"
            },
            {
              "goto": "s13",
              "id": "policy-change",
              "label": "Existing patient, policy change re-acknowledgment"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "New patient or existing-patient policy re-acknowledgment?"
        },
        {
          "detail": "Send via patient portal link, email, text-to-form link, or mailed/handed paper packet, depending on the practice's default channel and any stated patient preference on file. Note the delivery method and date in the patient's record.\n\nWhy: Delivery method and date matter later if a patient disputes ever having received the policy.\n\nRecord: Delivery channel and date logged in the patient's file",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Deliver the packet through the patient's preferred or default channel",
          "why": "Delivery method and date matter later if a patient disputes ever having received the policy."
        },
        {
          "detail": "Briefly explain, in plain language, the payment-due-at-service expectation, how insurance estimates are handled, the cancellation/no-show notice window, and any associated fee, before asking for a signature.\n\nWhy: A signature obtained without the terms being explained is easier for a patient to later dispute and weaker for staff to enforce when a fee is applied.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Walk the patient through the financial and cancellation policy",
          "why": "A signature obtained without the terms being explained is easier for a patient to later dispute and weaker for staff to enforce when a fee is applied."
        },
        {
          "detail": "Obtain a signature (wet or e-signature) on the financial policy, cancellation policy, communication consent, and HIPAA acknowledgment. For a minor patient, obtain the signature of the parent or legal guardian.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Capture signatures on all required documents"
        },
        {
          "detail": "Do not enroll the patient in automated appointment-reminder texts, marketing texts, or auto-dialed calls until the just-signed communication consent form shows an affirmative opt-in. Record the scope of consent (appointment reminders only vs. marketing) and the date before any enrollment happens.\n\nWhy: TCPA requires prior express consent before automated texts or calls; enrolling a patient in reminder texts before signed consent is on file exposes the practice to per-message liability.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent gate: confirm communication opt-in is signed before automated texts or calls begin.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "front-desk",
          "title": "Consent gate: confirm communication opt-in is signed before automated texts or calls begin",
          "why": "TCPA requires prior express consent before automated texts or calls; enrolling a patient in reminder texts before signed consent is on file exposes the practice to per-message liability."
        },
        {
          "detail": "Check whether all signed forms and the health history have come back with enough lead time before the scheduled visit.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "returned",
              "label": "Returned complete"
            },
            {
              "goto": "s14",
              "id": "not-returned",
              "label": "Not returned or incomplete close to appointment"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "front-desk",
          "title": "Has the completed packet been returned before the appointment?"
        },
        {
          "detail": "Store the signed financial policy, cancellation policy, communication consent, HIPAA acknowledgment, and intake/health-history forms in the patient's chart (paper file or practice-management system document tab), and mark the acknowledgment checklist complete in the front-desk log.\n\nRecord: Signed acknowledgment set filed in the patient's chart; acknowledgment log entry dated and initialed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "File the completed, signed acknowledgment set in the patient's record"
        },
        {
          "detail": "Route the completed health history and any noted allergies, medications, or medical alerts to the assistant or dentist seeing the patient, ahead of the appointment start time.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off completed health history to clinical staff before the appointment"
        },
        {
          "detail": "Patient has a fully documented, signed acknowledgment set on file before or at the first visit; communication consent scope is recorded; clinical staff has the health history in hand.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Welcome packet and policy acknowledgment complete"
        },
        {
          "detail": "Send a short notice (portal message, email, or mailed letter) stating what changed (e.g. cancellation notice window extended, late fee amount, new payment methods accepted) and the effective date, with a link or attachment to the updated document and a re-acknowledgment request.\n\nWhy: A policy is only enforceable against a patient who had fair notice of it before the event it governs (e.g. a no-show fee applied under a policy the patient never saw).",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify existing patients of the policy change",
          "why": "A policy is only enforceable against a patient who had fair notice of it before the event it governs (e.g. a no-show fee applied under a policy the patient never saw)."
        },
        {
          "detail": "Send one follow-up reminder through the consented channel. If the appointment is within 24-48 hours and forms are still outstanding, flag the chart so front desk collects paper copies at check-in instead of delaying the visit.\n\nWhy: Missing paperwork should not by itself cause a same-day cancellation once the patient is already scheduled and consented for care; the practical fallback is same-day completion.",
          "id": "s14",
          "kind": "step",
          "role": "front-desk",
          "title": "Send a reminder or plan to complete forms at check-in",
          "why": "Missing paperwork should not by itself cause a same-day cancellation once the patient is already scheduled and consented for care; the practical fallback is same-day completion."
        }
      ],
      "subclass": "patient-letters-forms-and-certificates",
      "summary": "New-patient welcome packet and practice-policy acknowledgment (financial, cancellation, communication) — A new patient is booked and forms are sent, or policies change and existing patients must re-acknowledge.",
      "title": "New-patient welcome packet and practice-policy acknowledgment (financial, cancellation, communication)",
      "trigger": "A new patient is booked and forms are sent, or policies change and existing patients must re-acknowledge",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "CA Penal §632 two-party consent for recorded calls",
          "source": "CA Penal §632 two-party consent for recorded calls",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=632",
          "url_verified_at": "2026-09-14"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "pofc-003",
      "kind": "clinical",
      "materials": [
        "after-hours triage script",
        "on-call schedule",
        "chart access (remote)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the caller reports difficulty breathing, swelling closing the airway, uncontrollable bleeding, chest pain, loss of consciousness, or a severe allergic reaction, instruct them to call 911 immediately or go to the nearest emergency department; do not attempt further triage on this line.\n\nWhy: Dental phone triage cannot manage an airway or cardiac emergency; the fastest path to care is EMS, not the office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Life-threatening symptoms? Direct to 911/EMS first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Life-threatening symptoms? Direct to 911/EMS first",
          "why": "Dental phone triage cannot manage an airway or cardiac emergency; the fastest path to care is EMS, not the office."
        },
        {
          "detail": "Confirm caller's name, date of birth, and the procedure/visit the call relates to; pull the chart if remote access is available.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Verify patient identity and recent procedure"
        },
        {
          "detail": "Onset and duration, pain level, bleeding, swelling location and trend, fever, medication taken and effect, any trauma since the visit.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Gather symptom detail"
        },
        {
          "detail": "Classify urgency",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "same-day",
              "label": "Same-day office visit needed (uncontrolled pain/bleeding not airway-threatening, spreading swelling)"
            },
            {
              "goto": "s9",
              "id": "next-day",
              "label": "Can be seen at next scheduled opening or added tomorrow"
            },
            {
              "goto": "s10",
              "id": "reassurance",
              "label": "Expected recovery symptom — reassurance and instructions sufficient"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Classify urgency"
        },
        {
          "detail": "Add the patient to tomorrow's or today's emergency slot; call patient back with the time; notify the opening team.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Arrange a same-day emergency slot"
        },
        {
          "detail": "The dentist taking the call confirms the triage decision (same-day, next-day, or reassurance) before it is communicated to the patient as final.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider confirms the triage disposition.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider confirms the triage disposition"
        },
        {
          "detail": "Log the following in the patient chart at this step: Call time, symptoms, triage decision, and any appointment made, logged in the patient chart the next business day.\n\nRecord: Call time, symptoms, triage decision, and any appointment made, logged in the patient chart the next business day.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Log the after-hours call and disposition"
        },
        {
          "detail": "After-hours call resolved",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "After-hours call resolved"
        },
        {
          "detail": "Add to the schedule at the next reasonable opening; give the patient a call-back number if symptoms worsen overnight.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule for next available appointment"
        },
        {
          "detail": "Explain that the symptom is within the expected recovery range, restate relevant home-care steps, and restate the warning signs that mean they should call back.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Provide reassurance and restate home-care instructions"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "After-hours patient call triage — emergency, same-day, next-day, reassurance — A patient calls the on-call emergency line outside office hours.",
      "title": "After-hours patient call triage — emergency, same-day, next-day, reassurance",
      "trigger": "A patient calls the on-call emergency line outside office hours",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "pofc-004",
      "kind": "clinical",
      "materials": [
        "symptom triage script",
        "chart access",
        "same-day appointment slot"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask when pain started relative to the procedure, whether it is worsening rather than improving, and whether over-the-counter or prescribed medication is providing any relief.\n\nWhy: Pain that worsens after day 2–3, rather than gradually improving, is the classic pattern the dentist needs to see promptly.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Phone-screen the pain complaint",
          "why": "Pain that worsens after day 2–3, rather than gradually improving, is the classic pattern the dentist needs to see promptly."
        },
        {
          "detail": "Is the pain worsening and not controlled by medication?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "worsening",
              "label": "Yes — worsening and/or medication not helping"
            },
            {
              "goto": "s10",
              "id": "stable",
              "label": "No — gradually improving, medication helping"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the pain worsening and not controlled by medication?"
        },
        {
          "detail": "Add the patient to today's schedule as an emergency exam; flag the chart for the dentist with the reported symptoms.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a same-day exam"
        },
        {
          "detail": "Check for an empty socket with exposed bone (dry socket), purulent drainage or fluctuant swelling (infection), a fractured tooth or restoration, occlusal high spots on any new restoration, and check temperature and note any facial swelling or other systemic signs; if fever or spreading swelling is found, stop and route to the swelling/fever/trismus escalation protocol (pofc-005) instead of continuing here.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Examine the site for cause"
        },
        {
          "detail": "What is the cause?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "dry-socket",
              "label": "Dry socket — pack and manage per office protocol"
            },
            {
              "goto": "s6",
              "id": "infection",
              "label": "Infection — assess for drainage/antibiotics per licensed judgment"
            },
            {
              "goto": "s6",
              "id": "fracture-occlusion",
              "label": "Fracture or high occlusion — adjust or refer for repair"
            },
            {
              "goto": "s11",
              "id": "unclear",
              "label": "Unclear — refer to specialist or imaging"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "What is the cause?"
        },
        {
          "detail": "Perform the indicated in-office treatment (socket packing, drainage, occlusal adjustment, or restoration repair) per the dentist's clinical judgment for this diagnosis.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Treat per licensed clinical judgment"
        },
        {
          "detail": "The treating dentist confirms the diagnosis and treatment rendered, and any new instructions given, before the patient leaves.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider confirms diagnosis and treatment before discharge.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider confirms diagnosis and treatment before discharge"
        },
        {
          "detail": "Log the following in the patient chart at this step: Exam findings, diagnosis, treatment rendered or referral made, and follow-up instructions, logged in the patient chart.\n\nRecord: Exam findings, diagnosis, treatment rendered or referral made, and follow-up instructions, logged in the patient chart.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Chart findings, diagnosis and treatment"
        },
        {
          "detail": "Pain complaint resolved or referred",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Pain complaint resolved or referred"
        },
        {
          "detail": "Confirm the pattern is within the expected recovery range and restate warning signs that mean they should call back or come in.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Reassure and give monitoring instructions"
        },
        {
          "detail": "Hand off to oral surgery or endodontics as indicated, with exam findings and imaging if taken.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to specialist for unclear or complex findings"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Post-op pain out of proportion — dry socket, infection, fracture or occlusion — A patient reports worsening pain days after a procedure.",
      "title": "Post-op pain out of proportion — dry socket, infection, fracture or occlusion",
      "trigger": "A patient reports worsening pain days after a procedure",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "pofc-005",
      "kind": "clinical",
      "materials": [
        "symptom triage script",
        "chart access",
        "nearest emergency department information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If swelling involves the floor of the mouth, is rapidly spreading, or the patient reports difficulty breathing or swallowing, instruct them to call 911 or go to the nearest emergency department immediately.\n\nWhy: Rapidly spreading facial or floor-of-mouth swelling can compromise the airway faster than an office visit can be arranged.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Airway-threatening swelling? Direct to 911/EMS first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Airway-threatening swelling? Direct to 911/EMS first",
          "why": "Rapidly spreading facial or floor-of-mouth swelling can compromise the airway faster than an office visit can be arranged."
        },
        {
          "detail": "Ask about swelling location and whether it is spreading, temperature if taken, and how far the patient can open (finger-widths) compared to before the procedure.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Phone-screen swelling, fever and trismus"
        },
        {
          "detail": "How severe are the symptoms?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "moderate-severe",
              "label": "Moderate-to-severe: notable swelling, fever, or marked trismus but not airway-threatening"
            },
            {
              "goto": "s11",
              "id": "mild",
              "label": "Mild and within expected early post-op range"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "How severe are the symptoms?"
        },
        {
          "detail": "Add the patient to today's schedule; flag the chart with reported temperature, swelling description, and opening measurement.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a same-day exam"
        },
        {
          "detail": "Measure interincisal opening, palpate for fluctuance, check for fever and other systemic signs, assess whether the swelling is localized or spreading.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Examine and assess systemic involvement"
        },
        {
          "detail": "Manage in office or send to emergency department?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "office-manage",
              "label": "Manageable in office (localized, no systemic signs)"
            },
            {
              "goto": "s12",
              "id": "ed-referral",
              "label": "Send to emergency department (systemic signs, spreading, or beyond office scope)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Manage in office or send to emergency department?"
        },
        {
          "detail": "Perform indicated in-office management (drainage, antibiotics per licensed judgment, or referral to oral surgery) and give updated home-care instructions.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Treat per licensed clinical judgment"
        },
        {
          "detail": "The treating dentist confirms the disposition decision (office management or ED referral) and instructions given.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider confirms disposition before patient leaves the call/visit.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider confirms disposition before patient leaves the call/visit"
        },
        {
          "detail": "Log the following in the patient chart at this step: Exam findings, temperature/opening measurements, disposition decision, and instructions given, logged in the patient chart.\n\nRecord: Exam findings, temperature/opening measurements, disposition decision, and instructions given, logged in the patient chart.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Chart findings, disposition and instructions"
        },
        {
          "detail": "Swelling/fever/trismus complaint resolved or referred",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Swelling/fever/trismus complaint resolved or referred"
        },
        {
          "detail": "Confirm the pattern is within the expected early post-op range and restate warning signs that mean they should call back or come in.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Reassure and give monitoring instructions"
        },
        {
          "detail": "Advise the patient to go to the nearest emergency department now; give a brief written summary of findings for the patient to bring if time allows.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to emergency department"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Post-op swelling, fever or trismus — office visit versus emergency department — A patient reports facial swelling, fever or inability to open.",
      "title": "Post-op swelling, fever or trismus — office visit versus emergency department",
      "trigger": "A patient reports facial swelling, fever or inability to open",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "pofc-006",
      "kind": "clinical",
      "materials": [
        "symptom triage script",
        "chart access",
        "sensory testing tools (cotton wisp, sharp/dull instrument)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask which anesthetic was used, which area is numb (lip, chin, tongue), and how long it has persisted compared to the typical duration for that anesthetic.\n\nWhy: Most local anesthetics resolve within hours; numbness persisting well beyond that window needs an in-person nerve exam.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Phone-screen the numbness report",
          "why": "Most local anesthetics resolve within hours; numbness persisting well beyond that window needs an in-person nerve exam."
        },
        {
          "detail": "Has numbness persisted well beyond the expected window?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "persisting",
              "label": "Yes — well beyond expected duration for the anesthetic used"
            },
            {
              "goto": "s10",
              "id": "expected",
              "label": "No — within the normal window for the anesthetic used"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Has numbness persisted well beyond the expected window?"
        },
        {
          "detail": "Add the patient to the schedule within a few days; flag the chart with the anesthetic used, procedure performed, and area affected.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule an in-person nerve exam"
        },
        {
          "detail": "Test light touch, sharp/dull discrimination, and two-point discrimination in the affected area; compare to the unaffected side; ask patient to map the numb area on a diagram.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Perform and document sensory testing"
        },
        {
          "detail": "Refer for nerve injury evaluation?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "refer",
              "label": "Refer to oral surgery/neurology for suspected nerve injury"
            },
            {
              "goto": "s11",
              "id": "monitor-office",
              "label": "Continue office monitoring with scheduled recheck"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Refer for nerve injury evaluation?"
        },
        {
          "detail": "Send exam findings, sensory map, and procedure details to oral surgery or neurology for evaluation.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Refer to specialist for nerve injury evaluation"
        },
        {
          "detail": "The treating dentist confirms the disposition — sensory exam findings and referral plan, or a reassurance-only closure within the expected window — before it is communicated as final.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider confirms the assessment and plan before it is communicated as final.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider confirms the assessment and plan before it is communicated as final"
        },
        {
          "detail": "Log the following in the patient chart at this step: Sensory exam findings, sensory map, referral or monitoring plan, logged in the patient chart.\n\nRecord: Sensory exam findings, sensory map, referral or monitoring plan, logged in the patient chart.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Chart sensory findings, plan and referral"
        },
        {
          "detail": "Numbness complaint evaluated and plan set",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Numbness complaint evaluated and plan set"
        },
        {
          "detail": "Confirm the duration is within the expected window and restate that they should call back if numbness persists further.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Reassure and give monitoring instructions"
        },
        {
          "detail": "Book a recheck appointment at an interval appropriate to the finding (commonly weeks) to reassess sensory recovery.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up recheck"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Numbness persisting beyond the expected window — A patient calls that they are still numb the next day.",
      "title": "Numbness persisting beyond the expected window",
      "trigger": "A patient calls that they are still numb the next day",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "pofc-007",
      "kind": "clinical",
      "materials": [
        "symptom triage script",
        "chart access showing current prescriptions and allergy list",
        "pharmacy contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the patient reports difficulty breathing or swallowing, throat or facial swelling, dizziness, or a rapidly spreading full-body rash: if epinephrine is prescribed, use it immediately, then call 911 or go to the nearest emergency department without delay.\n\nWhy: A severe drug reaction can progress to anaphylaxis quickly; phone triage cannot manage an airway emergency.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Signs of anaphylaxis or airway involvement? Direct to 911/EMS first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Signs of anaphylaxis or airway involvement? Direct to 911/EMS first",
          "why": "A severe drug reaction can progress to anaphylaxis quickly; phone triage cannot manage an airway emergency."
        },
        {
          "detail": "Ask which medication, when it was started, what the reaction looks like (rash, hives, itching, swelling location), and whether it is localized or spreading.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Phone-screen the reaction"
        },
        {
          "detail": "How severe is the reaction?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "moderate",
              "label": "Localized rash/itching, not spreading, no airway or facial involvement"
            },
            {
              "goto": "s4",
              "id": "mild",
              "label": "Mild, patient uncertain if related"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "How severe is the reaction?"
        },
        {
          "detail": "Cross-reference the reported symptoms with the prescribed medication and the patient's existing allergy list; decide whether to advise stopping the medication.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews the reported reaction against the medication"
        },
        {
          "detail": "Advise stopping the medication?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "stop-med",
              "label": "Advise stopping the medication and contact pharmacy/coordinate with prescriber if not the dentist"
            },
            {
              "goto": "s11",
              "id": "continue-monitor",
              "label": "Reaction unlikely related — advise continuing and monitoring"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Advise stopping the medication?"
        },
        {
          "detail": "Contact the pharmacy or coordinating prescriber about the reaction and the medication change; add the medication to the patient's chart allergy/adverse-reaction list.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Notify pharmacy and update allergy list"
        },
        {
          "detail": "For a significant or unexpected reaction, complete a voluntary FDA MedWatch Form 3500 report per practice policy.\n\nWhy: Adverse-event reporting under the FDA MedWatch program helps identify patterns beyond this one patient.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Consider a MedWatch adverse-event report",
          "why": "Adverse-event reporting under the FDA MedWatch program helps identify patterns beyond this one patient."
        },
        {
          "detail": "The treating dentist confirms the assessment, medication decision, and allergy-list update before it is communicated as final.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider confirms the reaction assessment and plan.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider confirms the reaction assessment and plan"
        },
        {
          "detail": "Log the following in the patient chart at this step: Reaction details, medication involved, decision made, pharmacy/prescriber notified, allergy-list update, and any MedWatch report filed, logged in the patient chart.\n\nRecord: Reaction details, medication involved, decision made, pharmacy/prescriber notified, allergy-list update, and any MedWatch report filed, logged in the patient chart.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Chart the reaction, decision and any report filed"
        },
        {
          "detail": "Medication reaction call resolved",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Medication reaction call resolved"
        },
        {
          "detail": "Confirm the reaction is likely unrelated or minor and restate warning signs that mean they should call back or go to the emergency department.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Reassure and give monitoring instructions"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Reported rash, itching or reaction to a prescribed medication — A patient calls about a reaction after starting a prescription.",
      "title": "Reported rash, itching or reaction to a prescribed medication",
      "trigger": "A patient calls about a reaction after starting a prescription",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "pofc-008",
      "kind": "clinical",
      "materials": [
        "symptom triage script",
        "chart access",
        "appointment scheduling"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "If the patient reports coughing, choking, gagging that does not resolve, or any difficulty breathing after something came loose or went missing, instruct them to call 911 or go to the nearest emergency department immediately.\n\nWhy: An aspirated foreign object in the airway is a medical emergency that a dental office cannot manage by phone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Signs of aspiration (coughing, choking, breathing trouble)? Direct to 911/EMS first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Signs of aspiration (coughing, choking, breathing trouble)? Direct to 911/EMS first",
          "why": "An aspirated foreign object in the airway is a medical emergency that a dental office cannot manage by phone."
        },
        {
          "detail": "Ask what came out or fell out, whether anything was swallowed, and confirm there is no ongoing coughing, choking, or breathing difficulty.\n\nWhy: A swallowed item usually passes harmlessly, but a possibly aspirated (inhaled) item is a respiratory emergency.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Screen what happened and whether anything was swallowed",
          "why": "A swallowed item usually passes harmlessly, but a possibly aspirated (inhaled) item is a respiratory emergency."
        },
        {
          "detail": "Was the item swallowed, or simply lost/fell out?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "swallowed-no-symptoms",
              "label": "Swallowed, no breathing/choking symptoms"
            },
            {
              "goto": "s9",
              "id": "lost-or-fell-out",
              "label": "Restoration or appliance fell out, not swallowed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Was the item swallowed, or simply lost/fell out?"
        },
        {
          "detail": "Explain that a swallowed dental item with no breathing or choking symptoms will usually pass through the digestive tract on its own; advise the patient to monitor and seek medical care for abdominal pain or if it does not pass in a few days.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Reassure on the swallowed item and advise monitoring"
        },
        {
          "detail": "Book the next reasonable appointment for re-cementation or a new restoration; advise the patient to avoid chewing on that side and to bring the piece if they have it.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a routine re-cementation or replacement appointment"
        },
        {
          "detail": "The dentist confirms the urgency assessment and scheduled follow-up before the call is closed out.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed provider confirms the scheduling/urgency decision.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed provider confirms the scheduling/urgency decision"
        },
        {
          "detail": "Log the following in the patient chart at this step: Item lost/swallowed, symptoms screened, urgency assessment, and appointment scheduled, logged in the patient chart.\n\nRecord: Item lost/swallowed, symptoms screened, urgency assessment, and appointment scheduled, logged in the patient chart.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Chart the call and scheduled follow-up"
        },
        {
          "detail": "Lost restoration or swallowed item call resolved",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Lost restoration or swallowed item call resolved"
        },
        {
          "detail": "Ask which tooth, whether it is a temporary or permanent restoration, whether the patient still has the piece, and whether there is pain, sharp edges, or sensitivity.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Screen the lost restoration"
        },
        {
          "detail": "How urgent is re-cementation or repair?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "urgent",
              "label": "Sharp edge, significant pain, or a temporary covering an active procedure (e.g. root canal in progress)"
            },
            {
              "goto": "s5",
              "id": "routine",
              "label": "No pain, no sharp edge, permanent restoration lost"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "front-desk",
          "title": "How urgent is re-cementation or repair?"
        },
        {
          "detail": "Add the patient to today's or the next available schedule slot; advise the patient to bring the piece if they have it.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a same-day or next-available visit"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Patient reports a lost crown, filling or swallowed appliance at home — A patient calls that something came out or was swallowed.",
      "title": "Patient reports a lost crown, filling or swallowed appliance at home",
      "trigger": "A patient calls that something came out or was swallowed",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        },
        {
          "kind": "generic",
          "label": "— periodic quality-review logging is a standard practice-management activity, not tied to a named methodology — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent — periodic quality-review logging is a standard practice-management activity, not tied to a named methodology"
          },
          "source": "— periodic quality-review logging is a standard practice-management activity, not tied to a named methodology — Practice policy — no published authority governs this step."
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "pofc-009",
      "kind": "clinical",
      "materials": [
        "complication log (spreadsheet or practice-management module)",
        "procedure schedule for the review period",
        "chart access for cross-reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Whoever takes a complication call or handles a complication visit adds a row to the complication log: date, patient chart number, procedure, procedure date, complication type, and immediate action taken.\n\nWhy: A log built in real time is complete; one reconstructed at month-end from memory is not.\n\nRecord: complication log entry (date, chart number, procedure, complication type, action taken)",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Log every complication call or visit as it happens",
          "why": "A log built in real time is complete; one reconstructed at month-end from memory is not."
        },
        {
          "detail": "The office manager schedules the recurring monthly review block and pulls the procedure schedule for the period alongside the complication log.",
          "id": "s2",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 2592000,
          "title": "Wait for the monthly review date"
        },
        {
          "detail": "Compile total procedures performed by type for the period and match each logged complication to its procedure type to compute a rate.\n\nWhy: A raw count of complications means little without the denominator of procedures performed.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the period's procedure counts and complication log entries",
          "why": "A raw count of complications means little without the denominator of procedures performed."
        },
        {
          "detail": "Walk through each logged complication: was it resolved, was the resolution timely, is there a pattern by procedure type, material, or technique.\n\nWhy: The point of the review is pattern detection, not individual case blame — this is a quality-improvement loop.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews the complication rates and individual cases",
          "why": "The point of the review is pattern detection, not individual case blame — this is a quality-improvement loop."
        },
        {
          "detail": "Does the data show a pattern worth acting on?\n\nWhy: A single outlier case is noise; a repeated pattern across several cases is signal that a protocol, material, or technique needs to change.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-pattern",
              "label": "No pattern — rates within normal range"
            },
            {
              "goto": "s8",
              "id": "pattern-found",
              "label": "A pattern is identified (e.g. elevated dry-socket rate after a specific procedure)"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the data show a pattern worth acting on?",
          "why": "A single outlier case is noise; a repeated pattern across several cases is signal that a protocol, material, or technique needs to change."
        },
        {
          "detail": "Save the completed review (rates, notable cases, any corrective actions) with the practice's quality records for the next review to reference.\n\nRecord: monthly complication review summary",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "File the monthly review summary"
        },
        {
          "detail": "Monthly review complete",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Monthly review complete"
        },
        {
          "detail": "Write down what was observed, the suspected contributing factor, and the change being made (e.g. updated post-op instructions, added a step to the sterilization or technique protocol, staff retraining).\n\nWhy: Turning a pattern into a documented change is what closes the quality-improvement loop rather than just noting a problem.\n\nRecord: pattern note and corrective action in the monthly review record",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the pattern and the planned response",
          "why": "Turning a pattern into a documented change is what closes the quality-improvement loop rather than just noting a problem."
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Post-treatment complication log and 30-day outcome review — Any complication call is received, or the monthly review is due.",
      "title": "Post-treatment complication log and 30-day outcome review",
      "trigger": "Any complication call is received, or the monthly review is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "HIPAA documentation requirements 45 CFR 164.530(j) — covered entities must document policies, procedures, actions, activities and communications required by the Privacy Rule",
          "source": "HIPAA documentation requirements 45 CFR 164.530(j) — covered entities must document policies, procedures, actions, activities and communications required by the Privacy Rule",
          "url": "https://www.ecfr.gov/current/title-45/section-164.530"
        },
        {
          "kind": "generic",
          "label": "— chairside injury assessment and documentation is standard clinical practice, not tied to a named methodology — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent — chairside injury assessment and documentation is standard clinical practice, not tied to a named methodology"
          },
          "source": "— chairside injury assessment and documentation is standard clinical practice, not tied to a named methodology — Practice policy — no published authority governs this step."
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "pofc-010",
      "kind": "clinical",
      "materials": [
        "gauze and cold compress",
        "topical protectant as clinically indicated",
        "camera for injury documentation",
        "incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note whether the injury is a chairside laceration or burn noticed during the visit, or a self-inflicted lip/cheek bite the patient reports after leaving while still numb.\n\nWhy: A chairside injury is disclosed and treated immediately; a numbness-related bite reported later is triaged by phone first.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the injury at the point it is noticed",
          "why": "A chairside injury is disclosed and treated immediately; a numbness-related bite reported later is triaged by phone first."
        },
        {
          "detail": "Assess the injury severity\n\nWhy: Most soft-tissue injuries and lip bites are minor and self-limiting; a small number need same-day evaluation or a referral.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "minor",
              "label": "Superficial, minor bleeding or redness, no deep tissue involvement"
            },
            {
              "goto": "s9",
              "id": "significant",
              "label": "Deep laceration, significant burn, or heavy bleeding"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess the injury severity",
          "why": "Most soft-tissue injuries and lip bites are minor and self-limiting; a small number need same-day evaluation or a referral."
        },
        {
          "detail": "Apply gauze/cold compress if chairside; if by phone, advise a cold compress, soft diet, and avoiding further trauma to the area while numbness persists. Give the standard timeframe by which it should resolve.\n\nWhy: Setting an expected resolution window gives the patient a clear signal for when to call back if it is not improving.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Provide chairside or phone care instructions",
          "why": "Setting an expected resolution window gives the patient a clear signal for when to call back if it is not improving."
        },
        {
          "detail": "Explain what happened, in plain terms, what was done about it, and what to expect during healing. This conversation happens whether the injury was chairside or reported later.\n\nWhy: Direct, prompt disclosure of an unintended injury is both the ethical standard of care and reduces the risk the patient feels something was hidden.\n\nRecord: disclosure conversation noted in the chart with date, time, and who was present",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist discloses the injury to the patient or caregiver directly.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist discloses the injury to the patient or caregiver directly",
          "why": "Direct, prompt disclosure of an unintended injury is both the ethical standard of care and reduces the risk the patient feels something was hidden."
        },
        {
          "detail": "Record what happened, when it was noticed, the care provided, the disclosure conversation, and a photo of the injury if practical and consented to.\n\nRecord: incident report + chart note + injury photo if consented",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the incident report and chart note"
        },
        {
          "detail": "Book a short follow-up visit or phone check within the expected healing window to confirm resolution.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Front desk schedules a follow-up check"
        },
        {
          "detail": "At the follow-up, confirm the injury has resolved as expected; if not, escalate to further evaluation or referral. Mark the incident record resolved.\n\nRecord: incident record marked resolved with follow-up outcome",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm resolution and close the incident record"
        },
        {
          "detail": "Incident closed",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Incident closed"
        },
        {
          "detail": "For a chairside injury, treat immediately (control bleeding, apply topical protectant, assess need for suture referral). For a reported bite/burn discovered after the visit, schedule a same-day visit to assess.\n\nWhy: A deep injury needs hands-on assessment, not phone reassurance alone.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Provide direct chairside treatment or arrange same-day evaluation",
          "why": "A deep injury needs hands-on assessment, not phone reassurance alone."
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Iatrogenic soft-tissue injury, chemical burn or self-inflicted lip bite after anesthesia — A patient sustains a laceration, thermal or chemical burn during care, or returns with a lip or cheek bite after numbing.",
      "title": "Iatrogenic soft-tissue injury, chemical burn or self-inflicted lip bite after anesthesia",
      "trigger": "A patient sustains a laceration, thermal or chemical burn during care, or returns with a lip or cheek bite after numbing",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Post-op call and after-hours triage scripts — generic functional equivalent"
          },
          "source": "Post-op call and after-hours triage scripts — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "pofc-012",
      "kind": "clinical",
      "materials": [
        "chart with materials used during the recent procedure",
        "allergy field in the patient record",
        "photo documentation of the reaction site if practical"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Before taking any history, ask whether there is any swelling of the face or throat, difficulty breathing or swallowing, or rapidly spreading hives; if so, instruct the patient to call 911 or go to the nearest emergency department immediately and do not continue this intake.\n\nWhy: A systemic allergic reaction can progress to airway compromise quickly, so screening for it must happen before history-taking, not after — mirrors the entry pattern used across this class's other emergency-capable protocols.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Facial/throat swelling or breathing difficulty? Direct to 911/EMS first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Facial/throat swelling or breathing difficulty? Direct to 911/EMS first",
          "why": "A systemic allergic reaction can progress to airway compromise quickly, so screening for it must happen before history-taking, not after — mirrors the entry pattern used across this class's other emergency-capable protocols."
        },
        {
          "detail": "Ask what the patient is experiencing (rash, itching, oral lesion, contact stomatitis), where, when it started relative to the procedure, and whether they have had similar reactions before.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the patient's report of the reaction"
        },
        {
          "detail": "Screen for signs of a severe or systemic reaction versus a localized one\n\nWhy: Facial/throat swelling, difficulty breathing, or hives spreading rapidly are signs of a systemic reaction that need emergency care, not a routine office visit — this protocol covers the localized, delayed presentation only.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "localized",
              "label": "Localized rash, itching, or oral lesion, no breathing or swelling concern"
            },
            {
              "goto": "s11",
              "id": "systemic-signs",
              "label": "Any swelling of face/throat, difficulty breathing, or rapidly spreading hives"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Screen for signs of a severe or systemic reaction versus a localized one",
          "why": "Facial/throat swelling, difficulty breathing, or hives spreading rapidly are signs of a systemic reaction that need emergency care, not a routine office visit — this protocol covers the localized, delayed presentation only."
        },
        {
          "detail": "Record the reported symptoms and schedule the patient to be seen promptly — same day if the symptoms are notably uncomfortable, otherwise within a few days.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the report and schedule a dentist evaluation"
        },
        {
          "detail": "Pull the chart note for the recent procedure and list every material that contacted the patient's tissue — latex gloves/dam, acrylic provisional, metal alloy, resin, impression material.\n\nWhy: Identifying the likely material is what turns a vague reaction report into an actionable allergy flag.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Cross-reference materials used at the recent procedure",
          "why": "Identifying the likely material is what turns a vague reaction report into an actionable allergy flag."
        },
        {
          "detail": "Examine the reaction site, compare against the materials list, and form a clinical impression of the likely cause.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Evaluate the patient at the scheduled visit"
        },
        {
          "detail": "Based on the exam, the dentist determines whether the reaction is likely material-related, what treatment (if any) is needed, and whether a specialist referral (allergist or dermatologist) is warranted for confirmation.\n\nWhy: A suspected material allergy is a clinical determination that changes future treatment planning — it needs the treating dentist's sign-off before it is added to the allergy record.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the suspected material and next steps.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the suspected material and next steps",
          "why": "A suspected material allergy is a clinical determination that changes future treatment planning — it needs the treating dentist's sign-off before it is added to the allergy record."
        },
        {
          "detail": "Update the allergy field in the patient record with the suspected material, the date, and the basis (reported reaction, clinical exam) so it flags automatically before future procedures using that material.\n\nWhy: The point of the whole workup is to make sure this material is never used on this patient again without a deliberate decision.\n\nRecord: allergy list updated with suspected material and basis",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Add the suspected material to the patient's allergy list",
          "why": "The point of the whole workup is to make sure this material is never used on this patient again without a deliberate decision."
        },
        {
          "detail": "Does the reaction warrant a specialist referral?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "no-referral",
              "label": "Mild, resolving reaction — no referral needed"
            },
            {
              "goto": "s12",
              "id": "referral",
              "label": "Persistent, recurrent, or unclear reaction — refer for confirmation"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the reaction warrant a specialist referral?"
        },
        {
          "detail": "Reaction workup complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Reaction workup complete"
        },
        {
          "detail": "Instruct the patient to call 911 or go to the nearest emergency department now; do not schedule a routine office visit for these symptoms.\n\nWhy: Signs of a systemic allergic reaction are a medical emergency outside the scope of a routine dental follow-up.\n\nRecord: call logged, patient advised to seek emergency care",
          "gate": {
            "ack": "I confirm I have completed this step as written: Redirect immediately to emergency care.",
            "type": "safety"
          },
          "id": "s11",
          "kind": "gate",
          "role": "front-desk",
          "title": "Redirect immediately to emergency care",
          "why": "Signs of a systemic allergic reaction are a medical emergency outside the scope of a routine dental follow-up."
        },
        {
          "detail": "Provide a written summary of the materials used and the reaction for the referral, and note the referral in the chart.\n\nRecord: referral sent with materials-used summary",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Refer to an allergist or dermatologist"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Delayed or localized allergic reaction to a dental material — A patient reports a rash, oral lichenoid lesion, itching or contact stomatitis days after latex, acrylic, metal or resin exposure.",
      "title": "Delayed or localized allergic reaction to a dental material",
      "trigger": "A patient reports a rash, oral lichenoid lesion, itching or contact stomatitis days after latex, acrylic, metal or resin exposure",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "source": "FDA MedWatch adverse-event reporting (21 CFR 803 for user facilities; voluntary Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        },
        {
          "kind": "regulation",
          "label": "21 CFR 803 — Medical Device Reporting for user facilities (mandatory reporting when a device caused or contributed to a death or serious injury)",
          "source": "21 CFR 803 — Medical Device Reporting for user facilities (mandatory reporting when a device caused or contributed to a death or serious injury)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-803"
        }
      ],
      "class": "postoperative-care-complications",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "pofc-013",
      "kind": "clinical",
      "materials": [
        "FDA MedWatch Form 3500 / 3500A",
        "device lot/serial number and manufacturer information",
        "incident report form",
        "imaging (radiograph) if aspiration or fracture is suspected"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If a fragment (bur, crown, instrument tip) may have been aspirated or swallowed, or the patient shows any airway distress, call 911 immediately and do not proceed with the rest of this protocol until the patient is safe.\n\nWhy: Non-negotiable #5: rule-based emergency response comes before any documentation or reporting workflow.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Address the immediate airway or injury risk first — call 911 if there is any.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Address the immediate airway or injury risk first — call 911 if there is any",
          "why": "Non-negotiable #5: rule-based emergency response comes before any documentation or reporting workflow."
        },
        {
          "detail": "Once the patient is safe, examine the injury or malfunction, retrieve the device or fragment if possible, and do not discard it — it may be needed for the manufacturer's investigation.\n\nWhy: The physical device is evidence for both the manufacturer's root-cause investigation and any MedWatch report.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Stabilize the patient and assess the device involved",
          "why": "The physical device is evidence for both the manufacturer's root-cause investigation and any MedWatch report."
        },
        {
          "detail": "Note the device name, manufacturer, lot/serial number, and how it was being used at the time of the malfunction or injury.\n\nRecord: device identification (name, manufacturer, lot/serial number, use context)",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Record device identification details"
        },
        {
          "detail": "Explain what happened, what was done about it, and what follow-up (imaging, referral, monitoring) is planned.\n\nWhy: Same disclosure standard as any iatrogenic incident — the patient should hear this from the dentist, promptly and directly.\n\nRecord: disclosure conversation noted in the chart",
          "gate": {
            "ack": "I confirm I have completed this step as written: Disclose the incident to the patient directly.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Disclose the incident to the patient directly",
          "why": "Same disclosure standard as any iatrogenic incident — the patient should hear this from the dentist, promptly and directly."
        },
        {
          "detail": "Did the device cause or contribute to a death or serious injury?\n\nWhy: 21 CFR 803 sets mandatory reporting for user facilities specifically when a device caused or contributed to a death or serious injury — this determination decides whether reporting is mandatory or discretionary.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "not-serious",
              "label": "Malfunction without death or serious injury (e.g. minor fragment retrieved without harm)"
            },
            {
              "goto": "s11",
              "id": "serious-or-death",
              "label": "Device caused or contributed to a death or serious injury"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Did the device cause or contribute to a death or serious injury?",
          "why": "21 CFR 803 sets mandatory reporting for user facilities specifically when a device caused or contributed to a death or serious injury — this determination decides whether reporting is mandatory or discretionary."
        },
        {
          "detail": "Is a voluntary MedWatch report (Form 3500) still appropriate?\n\nWhy: Even without a mandatory threshold, a device malfunction pattern is useful safety signal to report voluntarily.",
          "forks": [
            {
              "goto": "s12",
              "id": "file-voluntary",
              "label": "File a voluntary report"
            },
            {
              "advised": true,
              "goto": "s7",
              "id": "no-report-needed",
              "label": "Isolated, minor event — no report needed, log internally only"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is a voluntary MedWatch report (Form 3500) still appropriate?",
          "why": "Even without a mandatory threshold, a device malfunction pattern is useful safety signal to report voluntarily."
        },
        {
          "detail": "Record the full incident in the internal device-incident log for pattern tracking, even though no external report was filed.\n\nRecord: internal device-incident log entry",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident internally without external filing"
        },
        {
          "detail": "Contact the manufacturer with the device lot/serial number and incident details to support their investigation and any recall determination.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the device manufacturer"
        },
        {
          "detail": "File the complete incident record: emergency response (if any), disclosure, device documentation, reporting decision and outcome, and manufacturer notification.\n\nRecord: complete adverse device event file",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the incident record with full documentation"
        },
        {
          "detail": "Adverse device event process complete",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Adverse device event process complete"
        },
        {
          "detail": "Confirm the case meets the 21 CFR 803 threshold and initiate Form 3500A (mandatory user-facility report) within the regulatory timeframe.\n\nWhy: This is a compliance and license-exposure decision, so it gets a named sign-off distinct from the clinical disclosure step.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms mandatory MedWatch reporting is required and timeline.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms mandatory MedWatch reporting is required and timeline",
          "why": "This is a compliance and license-exposure decision, so it gets a named sign-off distinct from the clinical disclosure step."
        },
        {
          "detail": "Complete Form 3500 (voluntary) or 3500A (mandatory) with device identification, incident description, and outcome, and submit to the FDA.\n\nRecord: MedWatch report filed with confirmation number",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the MedWatch report"
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Serious device malfunction or patient injury from a device — reporting decision — An implant fractures, a bur breaks and is aspirated, or a curing light burns a patient.",
      "title": "Serious device malfunction or patient injury from a device — reporting decision",
      "trigger": "An implant fractures, a bur breaks and is aspirated, or a curing light burns a patient",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA decedent rules 45 CFR 164.502(f) and right of access 164.524",
          "source": "HIPAA decedent rules 45 CFR 164.502(f) and right of access 164.524",
          "url": "https://www.ecfr.gov/current/title-45/section-164.502"
        },
        {
          "kind": "generic",
          "label": "— notification-of-death response sequencing (verify, preserve record, notify carrier/counsel, controlled response) is standard risk-management practice, not tied to a named methodology — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent — notification-of-death response sequencing (verify, preserve record, notify carrier/counsel, controlled response) is standard risk-management practice, not tied to a named methodology"
          },
          "source": "— notification-of-death response sequencing (verify, preserve record, notify carrier/counsel, controlled response) is standard risk-management practice, not tied to a named methodology — Practice policy — no published authority governs this step."
        }
      ],
      "class": "postoperative-care-complications",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "pofc-014",
      "kind": "clinical",
      "materials": [
        "complete patient chart (locked from further edits pending review)",
        "malpractice carrier contact information",
        "legal counsel contact information",
        "incident report form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Note who called (family member, coroner, attorney, law enforcement), their contact information, what they said happened, and the date/time of the call. Do not speculate or offer opinions about cause.\n\nWhy: Exactly what was said and by whom becomes important later; do not editorialize while capturing it.\n\nRecord: notification log: reporter identity, relationship, date/time, and exact statement",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the notification and record who reported it",
          "why": "Exactly what was said and by whom becomes important later; do not editorialize while capturing it."
        },
        {
          "detail": "Can the reporter's identity and authority be reasonably verified?\n\nWhy: This determination controls what, if anything, can be discussed or released — treating an unverified caller as fully authorized risks releasing PHI without legal basis.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "verified-official",
              "label": "Verified official (coroner, law enforcement, or attorney with documentation)"
            },
            {
              "goto": "s11",
              "id": "unverified-family",
              "label": "Family member, identity/authority not yet verified"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Can the reporter's identity and authority be reasonably verified?",
          "why": "This determination controls what, if anything, can be discussed or released — treating an unverified caller as fully authorized risks releasing PHI without legal basis."
        },
        {
          "detail": "Lock the patient's chart from further edits (or, if the system cannot lock records, export and preserve a timestamped copy) so the treatment record as it existed at the time of the visit is protected.\n\nWhy: An unaltered, timestamped record is the single most important protection for both the truth of what happened and the practice's own position — this must happen before any other internal discussion.\n\nRecord: chart locked/preserved with timestamp",
          "gate": {
            "ack": "I confirm I have completed this step as written: Preserve the complete chart before any further action.",
            "role": "practice owner / compliance officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Preserve the complete chart before any further action",
          "why": "An unaltered, timestamped record is the single most important protection for both the truth of what happened and the practice's own position — this must happen before any other internal discussion."
        },
        {
          "detail": "Call the malpractice insurance carrier's incident-reporting line and report the notification received. Follow their guidance on next steps and documentation.\n\nWhy: Malpractice carriers require prompt notification of a potential claim, and their risk-management team is best positioned to guide the next steps correctly.",
          "id": "s4",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the malpractice carrier immediately",
          "why": "Malpractice carriers require prompt notification of a potential claim, and their risk-management team is best positioned to guide the next steps correctly."
        },
        {
          "detail": "Engage legal counsel (often provided or coordinated through the malpractice carrier) before any further external communication about the death.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Contact legal counsel"
        },
        {
          "detail": "Gather the facts from the staff who were involved in the patient's care, once, with counsel's input on how the conversation should be documented (or not).\n\nWhy: A single, counsel-guided fact-gathering conversation avoids staff independently speculating or discussing the case in ways that could create inconsistent statements.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Brief the treating dentist and relevant staff, once, under counsel's guidance",
          "why": "A single, counsel-guided fact-gathering conversation avoids staff independently speculating or discussing the case in ways that could create inconsistent statements."
        },
        {
          "detail": "Identify one person (typically the practice owner or counsel) as the only one authorized to speak with the family, coroner, attorney, media, or law enforcement going forward. All other staff are instructed to route any inquiry to that person.\n\nWhy: A sentinel event like this needs one controlled communication channel — multiple staff fielding questions independently is how inconsistent or premature statements happen.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Designate a single spokesperson for any further external contact",
          "why": "A sentinel event like this needs one controlled communication channel — multiple staff fielding questions independently is how inconsistent or premature statements happen."
        },
        {
          "detail": "Before releasing any part of the chart to a coroner, attorney, family member, or law enforcement, confirm the legal basis (subpoena, court order, verified personal representative status, or coroner's statutory authority) per HIPAA decedent rules — never release based on a phone request alone.\n\nWhy: 45 CFR 164.502(f) permits certain decedent disclosures but only within specific legal bases; releasing outside that basis is a HIPAA violation on top of an already sensitive event.\n\nRecord: records release log: what was released, to whom, and the legal basis confirmed",
          "gate": {
            "ack": "I confirm I have completed this step as written: Any records release requires confirmed legal authority.",
            "role": "compliance officer, with counsel",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Any records release requires confirmed legal authority",
          "why": "45 CFR 164.502(f) permits certain decedent disclosures but only within specific legal bases; releasing outside that basis is a HIPAA violation on top of an already sensitive event."
        },
        {
          "detail": "Keep the notification log, chart preservation record, carrier and counsel correspondence, and records-release log together as a single incident file, maintained per counsel's guidance on retention.\n\nRecord: complete sentinel-event incident file",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Maintain the complete incident file under counsel's direction"
        },
        {
          "detail": "Initial response process complete — ongoing matter proceeds under counsel's direction",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Initial response process complete — ongoing matter proceeds under counsel's direction"
        },
        {
          "detail": "Express condolences, take down the caller's contact information, and explain that any records will be handled per HIPAA decedent rules once the practice's process is followed. Do not confirm or deny clinical details on this call.\n\nWhy: Compassion does not require, and should not include, releasing PHI to an unverified party under emotional pressure.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Give a controlled, compassionate response without releasing records",
          "why": "Compassion does not require, and should not include, releasing PHI to an unverified party under emotional pressure."
        }
      ],
      "subclass": "post-op-follow-up-and-clinical-incidents",
      "summary": "Notification that a patient died after a recent visit — A family member, coroner, attorney or law-enforcement officer informs the office that a patient died within days of treatment.",
      "title": "Notification that a patient died after a recent visit",
      "trigger": "A family member, coroner, attorney or law-enforcement officer informs the office that a patient died within days of treatment",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California minor consent, Family Code §6910–6929",
          "source": "California minor consent, Family Code §6910–6929",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=FAM&sectionNum=6910."
        },
        {
          "kind": "regulation",
          "label": "No disability-accommodation statute (CA Unruh Act or federal ADA Title III) governs who may consent for a minor's dental treatment, custody documentation, or handling of unaccompanied minors — generic functional equivalent pending a family-law/consent-specific authority",
          "repaired": {
            "action": "generic",
            "evidence": "The fetched text: 'PART 36—NONDISCRIMINATION ON THE BASIS OF DISABILITY BY PUBLIC ACCOMMODATIONS AND IN COMMERCIAL FACILITIES ... implement[s] subtitle A of title III of the Americans with Disabilities Act of 1990 (42 U.S.C. 12181-12189)' — this is disability nondiscrimination law, unrelated to who may legally consent for a minor's care.",
            "ticket": "PROT-017",
            "was": {
              "source": "CA Unruh Act / general patient-rights floor for accommodation and equal service",
              "url": "https://www.ecfr.gov/current/title-28/part-36"
            }
          },
          "source": "No applicable authority — the cited text is federal ADA Title III public-accommodation regulation (28 CFR Part 36), not the CA Unruh Act, and neither addresses minor-consent procedure — generic functional equivalent"
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "prc-001",
      "kind": "operational",
      "materials": [
        "consent form",
        "custody or guardianship documentation folder",
        "emergency contact form",
        "state minor-consent quick-reference card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "caregiver",
        "patient",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm the minor's name and date of birth against the chart, and note who accompanied them (parent, grandparent, nanny, sibling, or alone).\n\nWhy: Who may legally consent depends on the relationship, not just presence in the waiting room.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Greet minor and accompanying adult",
          "why": "Who may legally consent depends on the relationship, not just presence in the waiting room."
        },
        {
          "detail": "Identify the accompanying adult's relationship to the minor.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "parent-guardian",
              "label": "Biological or adoptive parent, or legal guardian present"
            },
            {
              "goto": "s7",
              "id": "non-custodial",
              "label": "Non-custodial parent or relative without custody paperwork"
            },
            {
              "goto": "s9",
              "id": "unaccompanied",
              "label": "Minor arrived alone or with a non-relative caregiver (nanny, coach)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Who is present with the minor?"
        },
        {
          "detail": "Check photo ID against the chart's listed guardian; if this is a new relationship on file, ask for the guardianship or adoption paperwork.\n\nWhy: Front desk staff, not the dentist, are the first checkpoint for consent authority.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify parent/guardian identity",
          "why": "Front desk staff, not the dentist, are the first checkpoint for consent authority."
        },
        {
          "detail": "Record who consented, their relationship to the minor, the ID or documentation reviewed, and the scope of care consented to, in the chart.\n\nRecord: Consent authority, relationship, documentation reviewed, and scope of care in the patient's chart",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Document consent and identity verification"
        },
        {
          "detail": "Notify the dentist or hygienist that consent is verified and treatment may proceed as scoped.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to clinical team"
        },
        {
          "detail": "Visit consent workflow complete",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Visit consent workflow complete"
        },
        {
          "detail": "Have the accompanying adult produce the custody order, decree, or written authorization from the custodial parent naming this person and this visit type. Without it, treatment other than an emergency evaluation does not proceed.\n\nWhy: Treating on the word of a non-custodial adult without documentation can expose the practice to a custody dispute and an unconsented-treatment claim.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Custody documentation review.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "office-manager",
          "title": "Custody documentation review",
          "why": "Treating on the word of a non-custodial adult without documentation can expose the practice to a custody dispute and an unconsented-treatment claim."
        },
        {
          "detail": "Is valid custody/consent documentation present?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "docs-valid",
              "label": "Documentation names this adult and this scope of care"
            },
            {
              "goto": "s12",
              "id": "docs-missing",
              "label": "No valid documentation, or it conflicts with the chart"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is valid custody/consent documentation present?"
        },
        {
          "detail": "Some states let emancipated minors, minors seeking specific categories of care, or minors above a state-set age self-consent to limited services (e.g. California Family Code §6910–6929 for specific circumstances). Use the practice's state-specific quick-reference card.\n\nWhy: State minor-consent statutes carve out narrow self-consent categories; treating outside them without a guardian is a compliance exposure.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Check whether this minor may self-consent",
          "why": "State minor-consent statutes carve out narrow self-consent categories; treating outside them without a guardian is a compliance exposure."
        },
        {
          "detail": "Does this minor qualify for self-consent under state law for this visit type?",
          "forks": [
            {
              "goto": "s4",
              "id": "qualifies",
              "label": "Minor qualifies under a documented statutory category"
            },
            {
              "advised": true,
              "goto": "s11",
              "id": "does-not-qualify",
              "label": "Minor does not qualify — no guardian reachable"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Does this minor qualify for self-consent under state law for this visit type?"
        },
        {
          "detail": "Call every emergency contact on file; if pain or urgency requires action before contact is made, proceed only with emergency evaluation per the defer-non-emergency path.\n\nWhy: A documented good-faith attempt to reach a guardian protects the practice if care must begin before consent is obtained.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Attempt to reach a parent or guardian by phone",
          "why": "A documented good-faith attempt to reach a guardian protects the practice if care must begin before consent is obtained."
        },
        {
          "detail": "Perform only pain/emergency evaluation and stabilization; defer elective and non-urgent treatment until a custodial parent or documented consent is obtained. Document the reason for deferral.\n\nWhy: Emergency care for a minor in distress is treated differently than elective care under most state minor-consent frameworks; deferring the rest protects both the child and the practice.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Limit visit to emergency evaluation only",
          "why": "Emergency care for a minor in distress is treated differently than elective care under most state minor-consent frameworks; deferring the rest protects both the child and the practice."
        },
        {
          "detail": "Flag the visit to the practice owner for follow-up on obtaining full consent before the next appointment.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify practice owner of deferred/limited treatment"
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Consent for a minor — who may consent, custody documents and unaccompanied minors — A minor arrives with a grandparent, nanny, non-custodial parent, sibling, or alone.",
      "title": "Consent for a minor — who may consent, custody documents and unaccompanied minors",
      "trigger": "A minor arrives with a grandparent, nanny, non-custodial parent, sibling, or alone",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California minor consent, Family Code §6910–6929 — surrogate/capacity framework adjacent to this class's public floor",
          "source": "California minor consent, Family Code §6910–6929 — surrogate/capacity framework adjacent to this class's public floor",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=FAM&sectionNum=6910."
        },
        {
          "kind": "statute",
          "label": "CA B&P §1680 (patient abandonment) — surrogate/capacity framework adjacent to this class's public floor",
          "source": "CA B&P §1680 (patient abandonment) — surrogate/capacity framework adjacent to this class's public floor",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1680."
        },
        {
          "kind": "regulation",
          "label": "CA Unruh Act / ADA Title III accommodation floor",
          "source": "CA Unruh Act / ADA Title III accommodation floor",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "prc-002",
      "kind": "operational",
      "materials": [
        "surrogate-consent documentation checklist",
        "conservatorship/POA copy folder",
        "informed-consent form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "caregiver",
        "patient",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "During intake or the treatment discussion, observe whether the adult patient can understand the proposed treatment, risks, and alternatives well enough to consent themselves.\n\nWhy: Capacity is assessed situationally, not assumed from a diagnosis label alone.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Note the capacity concern",
          "why": "Capacity is assessed situationally, not assumed from a diagnosis label alone."
        },
        {
          "detail": "Can the patient understand and consent themselves today?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "has-capacity",
              "label": "Patient can understand and consent to this specific treatment"
            },
            {
              "goto": "s5",
              "id": "lacks-capacity",
              "label": "Patient cannot understand this treatment discussion"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Can the patient understand and consent themselves today?"
        },
        {
          "detail": "Proceed with the normal informed-consent process; a caregiver may still be present to support communication.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Obtain standard informed consent directly from patient"
        },
        {
          "detail": "Surrogate-consent workflow complete",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Surrogate-consent workflow complete"
        },
        {
          "detail": "Ask the accompanying caregiver what legal authority they hold: conservator, power of attorney for health care, or informal family caregiver with no legal document.\n\nWhy: Not every caregiver has legal authority to consent to treatment on the patient's behalf.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify who is claiming surrogate authority",
          "why": "Not every caregiver has legal authority to consent to treatment on the patient's behalf."
        },
        {
          "detail": "Request the conservatorship order or health care power of attorney document; confirm it names this person and covers medical/dental decisions, and check for an expiration or revocation.\n\nWhy: Treating based on an unverified or expired authority document is functionally treating without consent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Review surrogate authority documentation.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "Review surrogate authority documentation",
          "why": "Treating based on an unverified or expired authority document is functionally treating without consent."
        },
        {
          "detail": "Is valid, current surrogate documentation on file?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "valid-docs",
              "label": "Documentation is valid, current, and covers this decision"
            },
            {
              "goto": "s10",
              "id": "no-valid-docs",
              "label": "No documentation, or it does not cover dental/medical decisions"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is valid, current surrogate documentation on file?"
        },
        {
          "detail": "Explain diagnosis, proposed treatment, risks, benefits, and alternatives to the documented surrogate, including the patient in the conversation to the extent they can participate.\n\nWhy: Surrogate consent does not remove the patient's right to be included and informed as far as their capacity allows.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Conduct the informed-consent discussion with the surrogate",
          "why": "Surrogate consent does not remove the patient's right to be included and informed as far as their capacity allows."
        },
        {
          "detail": "File a copy of the conservatorship/POA document and record who consented, their legal authority, and the scope of treatment discussed, in the chart.\n\nRecord: Surrogate identity, authority document reference, and consented scope of treatment in the patient's chart",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Document surrogate identity and consent"
        },
        {
          "detail": "Provide only emergency pain relief or infection control; document that elective treatment is deferred pending valid surrogate documentation.\n\nWhy: Emergency care may proceed under a lower consent bar than elective treatment when a documented surrogate is not yet confirmed.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Limit care to emergency stabilization only",
          "why": "Emergency care may proceed under a lower consent bar than elective treatment when a documented surrogate is not yet confirmed."
        },
        {
          "detail": "Notify the office manager to request updated surrogate documentation before the next non-emergency visit.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag for follow-up on obtaining valid documentation"
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Adult with limited decision-making capacity — conservator, power of attorney or surrogate consent verification — A caregiver presents with an adult patient who cannot understand the treatment discussion.",
      "title": "Adult with limited decision-making capacity — conservator, power of attorney or surrogate consent verification",
      "trigger": "A caregiver presents with an adult patient who cannot understand the treatment discussion",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Section 1557 language access and effective communication, 45 CFR Part 92",
          "source": "Section 1557 language access and effective communication, 45 CFR Part 92",
          "url": "https://www.ecfr.gov/current/title-45/part-92"
        },
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations, 28 CFR Part 36 (effective communication for Deaf/hard-of-hearing patients)",
          "source": "ADA Title III public accommodations, 28 CFR Part 36 (effective communication for Deaf/hard-of-hearing patients)",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "prc-003",
      "kind": "operational",
      "materials": [
        "language-line phone/tablet access",
        "sign-language interpreter service contact list",
        "translated consent form set (where available)",
        "language preference field in the scheduling system"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "scheduler",
        "dentist",
        "treatment-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note the patient's preferred spoken language, or that they are Deaf/hard-of-hearing and need a sign-language interpreter, at scheduling or check-in.\n\nWhy: Arranging an interpreter in advance avoids delaying or degrading the visit.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the language or communication need",
          "why": "Arranging an interpreter in advance avoids delaying or degrading the visit."
        },
        {
          "detail": "A companion may volunteer to interpret informally.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "professional-interpreter",
              "label": "Arrange a qualified professional interpreter instead"
            },
            {
              "goto": "s9",
              "id": "accept-family-interpreter",
              "label": "Accept the family member as interpreter"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Has a family member or friend offered to interpret?"
        },
        {
          "detail": "Book a live in-person or video/phone interpreter (or a certified sign-language interpreter) for the appointment slot, matched to the patient's stated language and modality preference.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Arrange the interpreter for the visit"
        },
        {
          "detail": "Confirm the interpreter booking is held at least 24 hours before the appointment; if unavailable, reschedule or arrange an on-demand phone/video service as a fallback.\n\nWhy: A patient arriving to find no interpreter present functionally denies them the ability to consent or understand care.",
          "id": "s4",
          "kind": "timer",
          "role": "scheduler",
          "timer_seconds": 86400,
          "title": "Confirm interpreter availability before the visit",
          "why": "A patient arriving to find no interpreter present functionally denies them the ability to consent or understand care."
        },
        {
          "detail": "Verify the interpreter (in-person, phone, or video) is connected and ready before the patient is brought back for treatment.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm interpreter presence at check-in"
        },
        {
          "detail": "Speak directly to the patient (not to the interpreter), pause for full interpretation, and confirm understanding of consent and treatment plan through the interpreter before proceeding.\n\nWhy: Effective communication means the patient understands, not just that words were relayed.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Conduct the visit through the interpreter",
          "why": "Effective communication means the patient understands, not just that words were relayed."
        },
        {
          "detail": "Note in the chart which interpreter service and language/modality was used for the visit, and update the patient's stored language preference.\n\nRecord: Language/interpreter service used and patient's language preference in the chart",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the language service used"
        },
        {
          "detail": "Language access workflow complete",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Language access workflow complete"
        },
        {
          "detail": "A family member or minor should not be relied on for clinically or legally significant conversations (consent, diagnosis, treatment risk) except in an emergency where no other option exists; offer the professional service as the default and document if the patient still prefers the family member for routine conversation only.\n\nWhy: A companion's interpretation can be inaccurate, incomplete, or influenced by their own interest in the outcome, and using a minor as interpreter has its own risk.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Explain the limits of a family-member interpreter",
          "why": "A companion's interpretation can be inaccurate, incomplete, or influenced by their own interest in the outcome, and using a minor as interpreter has its own risk."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Language access — interpreter arrangement and documentation for limited-English or Deaf patients — A patient or caregiver cannot communicate in the office's languages, requests a sign-language interpreter, or a family member offers to interpret.",
      "title": "Language access — interpreter arrangement and documentation for limited-English or Deaf patients",
      "trigger": "A patient or caregiver cannot communicate in the office's languages, requests a sign-language interpreter, or a family member offers to interpret",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations, 28 CFR Part 36",
          "source": "ADA Title III public accommodations, 28 CFR Part 36",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        },
        {
          "kind": "statute",
          "label": "CA Unruh Act (Civil Code §51)",
          "source": "CA Unruh Act (Civil Code §51)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=51."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "prc-004",
      "kind": "operational",
      "materials": [
        "accommodation request log",
        "accessible operatory/room availability list",
        "service-animal two-question script"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "dentist",
        "assistant",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note what the patient is requesting (accessible entry/room, extra time, quiet space, written communication, service animal accompaniment) at scheduling or check-in.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive the accommodation request"
        },
        {
          "detail": "Does the request involve a service animal?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "not-service-animal",
              "label": "No — request is mobility/hearing/vision/cognitive/time related"
            },
            {
              "goto": "s8",
              "id": "is-service-animal",
              "label": "Yes — patient has a service animal"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the request involve a service animal?"
        },
        {
          "detail": "Check accessible room/operatory availability, whether extra appointment time is needed, and whether any physical layout adjustment (ramp, transfer space) is required for this visit.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Assess what the office can provide"
        },
        {
          "detail": "Can the request be accommodated as asked?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "can-accommodate",
              "label": "Yes — schedule with the accommodation in place"
            },
            {
              "goto": "s9",
              "id": "needs-alternative",
              "label": "Not exactly as requested — an equally effective alternative exists"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Can the request be accommodated as asked?"
        },
        {
          "detail": "Block the accessible room, add extra time, and flag the chart so clinical staff are prepared before the patient arrives.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule with the accommodation applied"
        },
        {
          "detail": "Record the accommodation type and outcome in the chart and the accommodation request log so future visits are prepared automatically.\n\nRecord: Accommodation type and fulfillment status in the chart and accommodation log",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the accommodation on file"
        },
        {
          "detail": "Accommodation request handled",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Accommodation request handled"
        },
        {
          "detail": "Ask only the two permitted questions: (1) is the animal required because of a disability, and (2) what work or task has it been trained to perform. Do not ask about the disability itself or require documentation.\n\nWhy: Federal accommodation rules limit what staff may ask about a service animal to protect patient privacy while allowing legitimate verification.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Apply the two-question service-animal policy",
          "why": "Federal accommodation rules limit what staff may ask about a service animal to protect patient privacy while allowing legitimate verification."
        },
        {
          "detail": "Propose an alternative that meets the same functional need (e.g. a different accessible room, a written-communication option) and confirm the patient accepts it before the visit.\n\nWhy: The accommodation duty is to provide effective access, not necessarily the exact form requested, but the substitute must genuinely work for the patient.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Offer and confirm an equally effective alternative",
          "why": "The accommodation duty is to provide effective access, not necessarily the exact form requested, but the substitute must genuinely work for the patient."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Disability accommodation request — mobility, hearing, vision, cognitive, service animal — A patient in a wheelchair, with a service animal, who is Deaf, or who needs extra time or a quiet room requests an accommodation.",
      "title": "Disability accommodation request — mobility, hearing, vision, cognitive, service animal",
      "trigger": "A patient in a wheelchair, with a service animal, who is Deaf, or who needs extra time or a quiet room requests an accommodation",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations, 28 CFR Part 36",
          "source": "ADA Title III public accommodations, 28 CFR Part 36",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        },
        {
          "kind": "statute",
          "label": "CA Unruh Act (Civil Code §51)",
          "source": "CA Unruh Act (Civil Code §51)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=CIV&sectionNum=51."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "annual",
      "id": "prc-005",
      "kind": "operational",
      "materials": [
        "ADA facility accessibility checklist",
        "website accessibility scan tool output",
        "prior year's self-assessment for comparison"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "marketing",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note whether this is the scheduled annual review, follows a remodel or website relaunch, or was prompted by a complaint or demand letter.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the trigger for this assessment"
        },
        {
          "detail": "Was this triggered by a complaint or demand letter?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "routine",
              "label": "No — this is a routine/scheduled review"
            },
            {
              "goto": "s8",
              "id": "complaint-triggered",
              "label": "Yes — a complaint or demand letter was received"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Was this triggered by a complaint or demand letter?"
        },
        {
          "detail": "Check accessible parking/path of travel, entrance ramp or level entry, door width and hardware, accessible restroom, clear floor space in at least one operatory, counter height at check-in, and signage.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Walk the physical facility against the accessibility checklist"
        },
        {
          "detail": "Scan the public website (or have the web vendor scan it) for common barriers: missing alt text, poor color contrast, keyboard navigation failures, and unlabeled form fields; log the results.\n\nWhy: Website accessibility has become a common source of demand letters even for practices with a fully accessible physical office.",
          "id": "s4",
          "kind": "step",
          "role": "it-vendor",
          "title": "Run an automated accessibility scan of the practice website",
          "why": "Website accessibility has become a common source of demand letters even for practices with a fully accessible physical office."
        },
        {
          "detail": "Rank findings by severity (barrier to entry/use vs. minor polish) and assign owners and target dates for each remediation item.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "Review findings and prioritize remediation"
        },
        {
          "detail": "File the completed checklist, scan results, and remediation plan with target dates in the compliance record.\n\nRecord: Facility checklist, website scan results, and remediation plan with owners and dates",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the self-assessment and remediation plan"
        },
        {
          "detail": "Accessibility self-assessment complete",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Accessibility self-assessment complete"
        },
        {
          "detail": "Do not respond directly to a demand letter without compliance and, where warranted, legal review; log the complaint and preserve all related correspondence.\n\nWhy: An accommodation complaint or demand letter can carry legal exposure that a routine front-desk response is not equipped to manage.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route complaint/demand letter through compliance review.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Route complaint/demand letter through compliance review",
          "why": "An accommodation complaint or demand letter can carry legal exposure that a routine front-desk response is not equipped to manage."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Facility and website accessibility self-assessment — The annual review, a remodel, a website relaunch, or an accessibility complaint or demand letter.",
      "title": "Facility and website accessibility self-assessment",
      "trigger": "The annual review, a remodel, a website relaunch, or an accessibility complaint or demand letter",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California mandated reporting of child abuse, Penal Code §11165.7 and §11166",
          "source": "California mandated reporting of child abuse, Penal Code §11165.7 and §11166",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=11166."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "prc-006",
      "kind": "operational",
      "materials": [
        "mandated reporter hotline number",
        "SCAR (Suspected Child Abuse Report) form or state equivalent",
        "intraoral/extraoral photo documentation kit (consented)",
        "incident documentation template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Note findings such as unexplained orofacial trauma, a torn frenum inconsistent with the stated cause, patterned bite marks, gross untreated dental disease inconsistent with access to care, or a direct disclosure from the child.\n\nWhy: Dentists and hygienists are positioned to notice orofacial injury patterns that other providers may not see.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Recognize signs consistent with abuse or neglect",
          "why": "Dentists and hygienists are positioned to notice orofacial injury patterns that other providers may not see."
        },
        {
          "detail": "If the child shows signs needing immediate medical attention (active bleeding, possible fracture, loss of consciousness, or signs of strangulation), call 911 or arrange urgent transport to the emergency department before any interview or documentation step below.\n\nWhy: A mandated-report workflow assumes the child is medically stable enough for a private conversation and documentation; an acute injury overrides that sequence entirely.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Emergency check — does the child need immediate medical attention? Call 911 first if so..",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Emergency check — does the child need immediate medical attention? Call 911 first if so.",
          "why": "A mandated-report workflow assumes the child is medically stable enough for a private conversation and documentation; an acute injury overrides that sequence entirely."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Suspected child abuse or neglect — recognition, documentation and mandated report (CA: immediate phone plus written report within 36 hours) — A child presents with unexplained orofacial injuries, a torn frenum, bite marks, gross dental neglect or a disclosure.",
      "title": "Suspected child abuse or neglect — recognition, documentation and mandated report (CA: immediate phone plus written report within 36 hours)",
      "trigger": "A child presents with unexplained orofacial injuries, a torn frenum, bite marks, gross dental neglect or a disclosure",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California elder and dependent adult abuse mandated reporting, Welfare & Institutions Code §15630",
          "source": "California elder and dependent adult abuse mandated reporting, Welfare & Institutions Code §15630",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC&sectionNum=15630."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "prc-007",
      "kind": "operational",
      "materials": [
        "Adult Protective Services hotline number",
        "elder/dependent-adult abuse report form or state equivalent",
        "incident documentation template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Note signs such as unexplained injuries, poor hygiene inconsistent with the caregiving situation, gross untreated dental disease, fearfulness around a caregiver, or apparent financial exploitation (e.g. caregiver controlling payment in an unusual way).\n\nWhy: Dental visits are often the periodic contact point where neglect or abuse of an older or dependent adult first becomes visible.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Recognize signs consistent with elder or dependent adult abuse or neglect",
          "why": "Dental visits are often the periodic contact point where neglect or abuse of an older or dependent adult first becomes visible."
        },
        {
          "detail": "If the patient shows signs needing immediate medical attention (active bleeding, possible fracture, signs of dehydration or medical crisis, or loss of consciousness), call 911 or arrange urgent transport to the emergency department before any private conversation or documentation step below.\n\nWhy: A mandated-report workflow assumes the patient is medically stable enough for a private conversation and documentation; an acute medical need overrides that sequence entirely.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Emergency check — does the patient need immediate medical attention? Call 911 first if so..",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Emergency check — does the patient need immediate medical attention? Call 911 first if so.",
          "why": "A mandated-report workflow assumes the patient is medically stable enough for a private conversation and documentation; an acute medical need overrides that sequence entirely."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Suspected elder or dependent adult abuse or neglect — mandated report — An older or dependent patient shows signs of neglect, financial exploitation or injury.",
      "title": "Suspected elder or dependent adult abuse or neglect — mandated report",
      "trigger": "An older or dependent patient shows signs of neglect, financial exploitation or injury",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA Penal Code §632 (recording/communication consent context) and this class's general mandated-reporting floor for adult patients where state law requires reporting of certain injuries",
          "source": "CA Penal Code §632 (recording/communication consent context) and this class's general mandated-reporting floor for adult patients where state law requires reporting of certain injuries",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=632."
        },
        {
          "kind": "generic",
          "label": "General patient-rights and confidentiality floor for this class — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "General patient-rights and confidentiality floor for this class"
          },
          "source": "General patient-rights and confidentiality floor for this class — Practice policy — no published authority governs this step."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "prc-008",
      "kind": "operational",
      "materials": [
        "national domestic violence hotline resource card",
        "local resource/shelter referral list",
        "private-room availability",
        "incident documentation template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk",
        "office-manager",
        "patient",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the disclosure happens in a shared space, move to a private room as soon as safely possible; listen without judgment and thank the patient for sharing.\n\nWhy: How the first response lands affects whether the patient will accept help or resources at all.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Receive the disclosure calmly and privately",
          "why": "How the first response lands affects whether the patient will accept help or resources at all."
        },
        {
          "detail": "Is the patient in immediate danger right now?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "not-immediate",
              "label": "No immediate danger in this moment"
            },
            {
              "goto": "s9",
              "id": "immediate-danger",
              "label": "Yes — patient fears an abuser is nearby or contact is imminent"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient in immediate danger right now?"
        },
        {
          "detail": "Tell the patient what will and will not be shared, and whether state law requires reporting certain injury types even for a competent adult who asks for confidentiality — be honest about this before the patient shares more.\n\nWhy: Adult IPV disclosures generally stay confidential unless state law creates a specific reporting duty (e.g. injuries by weapon in some states); telling the patient the limits upfront respects their autonomy.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Clarify confidentiality and any reporting limits with the patient",
          "why": "Adult IPV disclosures generally stay confidential unless state law creates a specific reporting duty (e.g. injuries by weapon in some states); telling the patient the limits upfront respects their autonomy."
        },
        {
          "detail": "Offer the national domestic violence hotline resource card and local resource list; let the patient take the information or decline it, and do not insist on any next step.\n\nWhy: Pressuring a patient to leave or act on their timeline can increase danger; offering options respects that the patient knows their situation best.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Offer resources without pressuring a decision",
          "why": "Pressuring a patient to leave or act on their timeline can increase danger; offering options respects that the patient knows their situation best."
        },
        {
          "detail": "Record injury findings in clinical terms and note that the patient disclosed IPV, without speculative detail beyond what the patient stated; note resources offered.\n\nRecord: Objective clinical findings, factual note of disclosure, and resources offered in the chart",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Document objective findings and disclosure factually"
        },
        {
          "detail": "Does state law require reporting for this injury type even without patient consent?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-mandate",
              "label": "No mandatory reporting duty applies for a competent adult here"
            },
            {
              "goto": "s10",
              "id": "mandate-applies",
              "label": "Yes — a state-specific mandatory report applies (e.g. weapon-inflicted injury in some states)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does state law require reporting for this injury type even without patient consent?"
        },
        {
          "detail": "Note in the chart (without detail visible to unrelated staff) that a supportive check-in should happen at the next visit, consistent with the patient's wishes.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Flag for follow-up support at future visits"
        },
        {
          "detail": "Disclosure response workflow complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Disclosure response workflow complete"
        },
        {
          "detail": "If the patient is in immediate danger, offer to call 911 and keep the patient in a secured private space until it is safe; do not release the patient into a waiting area where the abuser may be present without a plan.\n\nWhy: A disclosure that includes fear of imminent harm is a safety emergency, not only a documentation event.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Immediate safety response.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "role": "office-manager",
          "title": "Immediate safety response",
          "why": "A disclosure that includes fear of imminent harm is a safety emergency, not only a documentation event."
        },
        {
          "detail": "File the report as required by the applicable state statute, and inform the patient this report is legally required and cannot be withheld.\n\nWhy: A small number of states require reporting of certain violent injuries regardless of the competent adult patient's wishes; telling the patient keeps the relationship honest.",
          "gate": {
            "ack": "I confirm I have completed this step as written: File the state-mandated report.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "File the state-mandated report",
          "why": "A small number of states require reporting of certain violent injuries regardless of the competent adult patient's wishes; telling the patient keeps the relationship honest."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Adult patient discloses intimate-partner violence or presents with injuries consistent with assault — A patient discloses abuse at home or asks the team not to tell anyone.",
      "title": "Adult patient discloses intimate-partner violence or presents with injuries consistent with assault",
      "trigger": "A patient discloses abuse at home or asks the team not to tell anyone",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §1680 (patient abandonment)",
          "source": "CA B&P §1680 (patient abandonment)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1680."
        },
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations 28 CFR Part 36 (dismissal may not be based on a protected characteristic)",
          "source": "ADA Title III public accommodations 28 CFR Part 36 (dismissal may not be based on a protected characteristic)",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "prc-009",
      "kind": "operational",
      "materials": [
        "dismissal letter template",
        "certified mail receipt form",
        "records-release authorization form",
        "emergency-coverage window tracking log",
        "state dental board patient abandonment guidance reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "office-manager",
        "front-desk",
        "patient",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The dentist or office manager documents the specific pattern (missed appointments, non-payment, non-adherence to treatment, threats) with dates in the chart note, separate from any protected-characteristic reason.\n\nWhy: A documented, non-discriminatory basis protects the practice if the dismissal is later challenged.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify and document the grounds for dismissal",
          "why": "A documented, non-discriminatory basis protects the practice if the dismissal is later challenged."
        },
        {
          "detail": "Could the true reason be read as a protected characteristic?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-clear-nondiscriminatory",
              "label": "No — grounds are clearly conduct, payment or adherence based"
            },
            {
              "goto": "s11",
              "id": "possible-protected",
              "label": "Uncertain or possible protected-characteristic overlap"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Could the true reason be read as a protected characteristic?"
        },
        {
          "detail": "The practice owner and the treating dentist review the documented grounds and both approve moving forward with formal dismissal.\n\nWhy: Ending a doctor-patient relationship is a licensure-consequential act; it never proceeds on one person's say-so.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner and treating dentist sign off on the dismissal.",
            "role": "practice owner and treating dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner and treating dentist sign off on the dismissal",
          "why": "Ending a doctor-patient relationship is a licensure-consequential act; it never proceeds on one person's say-so."
        },
        {
          "detail": "Draft a letter stating the relationship is ending, the effective date, that the practice will provide emergency-only care for a fixed window (practice's chosen period, no shorter than the state-recognized reasonable notice standard) from the letter date, and an offer to transfer records on written authorization.\n\nWhy: Written notice with a defined transition window is what separates a lawful dismissal from abandonment under state dental-board standards.\n\nRecord: dismissal letter draft in patient's file",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft the written dismissal letter",
          "why": "Written notice with a defined transition window is what separates a lawful dismissal from abandonment under state dental-board standards."
        },
        {
          "detail": "Mail the dismissal letter certified, return receipt requested, to the patient's address of record; also send a standard first-class copy in case certified mail is refused.\n\nWhy: Proof of delivery attempt is the practice's evidence that notice was given, whether or not the patient ultimately reads it.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the letter by certified mail with return receipt",
          "why": "Proof of delivery attempt is the practice's evidence that notice was given, whether or not the patient ultimately reads it."
        },
        {
          "detail": "Log the start date of the emergency-coverage window from the postmark/mail date; the front desk continues to see the patient for emergencies only during this window even without a scheduled next appointment.\n\nWhy: Refusing all care during the notice window, including true emergencies, is itself a form of abandonment.",
          "id": "s6",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 2592000,
          "title": "Emergency-only coverage window (practice-set, minimum per letter date)",
          "why": "Refusing all care during the notice window, including true emergencies, is itself a form of abandonment."
        },
        {
          "detail": "Does the patient request a records transfer?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "requests-transfer",
              "label": "Patient signs a records-release authorization"
            },
            {
              "goto": "s9",
              "id": "no-request-yet",
              "label": "No request received during the window"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient request a records transfer?"
        },
        {
          "detail": "Copy or transfer the requested records to the new provider or the patient within the state's required timeframe once the signed authorization is received.\n\nRecord: signed records-release authorization and date records were sent, logged in the patient's file",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Process the records transfer"
        },
        {
          "detail": "Enter the dismissal date, mail receipt confirmation, coverage-window end date, and records-transfer status into the compliance tracking log.\n\nRecord: dismissal date, mail receipt, coverage-window end date, and records-transfer status logged in the compliance tracking log",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Close out the dismissal in the practice log"
        },
        {
          "detail": "Dismissal completed without abandonment",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Dismissal completed without abandonment"
        },
        {
          "detail": "Route to the compliance officer or outside counsel to confirm the dismissal is not, or does not appear to be, based on a protected characteristic before any letter is sent.\n\nWhy: Dismissal for a discriminatory reason exposes the practice to civil rights liability regardless of the stated non-payment or conduct grounds.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review before proceeding with dismissal.",
            "role": "compliance officer or outside counsel",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review before proceeding with dismissal",
          "why": "Dismissal for a discriminatory reason exposes the practice to civil rights liability regardless of the stated non-payment or conduct grounds."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Dismissing a patient from the practice without abandonment (written notice, 30-day emergency coverage, records offer) — Repeated no-shows, non-payment, threats or non-adherence lead the dentist and owner to end the relationship.",
      "title": "Dismissing a patient from the practice without abandonment (written notice, 30-day emergency coverage, records offer)",
      "trigger": "Repeated no-shows, non-payment, threats or non-adherence lead the dentist and owner to end the relationship",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA Penal Code §632 (recording consent — two-party consent for confidential communications)",
          "source": "CA Penal Code §632 (recording consent — two-party consent for confidential communications)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=632."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "prc-010",
      "kind": "operational",
      "materials": [
        "office recording/photography policy sign",
        "verbal consent script card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "office-manager",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Staff notices a phone or camera being used to record, or the patient explicitly asks permission to record the visit.\n\nWhy: California is a two-party consent state for confidential communications; recording without consent from everyone captured can be unlawful.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Staff notices or is asked about recording",
          "why": "California is a two-party consent state for confidential communications; recording without consent from everyone captured can be unlawful."
        },
        {
          "detail": "Did the patient ask first, or is this an unconsented recording already in progress?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "asked-first",
              "label": "Patient asked permission before recording"
            },
            {
              "goto": "s3",
              "id": "already-recording",
              "label": "Recording is already happening without consent"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the patient ask first, or is this an unconsented recording already in progress?"
        },
        {
          "detail": "Before allowing the recording to continue, identify who else appears or is audible in the recording (other staff, other patients) and confirm each person present consents, or ask the patient to record only their own consultation with staff visible on-frame consenting.\n\nWhy: Any staff or bystander captured is also a party whose consent is required under §632; the office cannot consent on their behalf.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent gate — confirm who is in frame and whether everyone consents.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "office-manager",
          "title": "Consent gate — confirm who is in frame and whether everyone consents",
          "why": "Any staff or bystander captured is also a party whose consent is required under §632; the office cannot consent on their behalf."
        },
        {
          "detail": "Do all captured parties consent to the recording?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "all-consent",
              "label": "Yes — dentist and any other staff in frame consent"
            },
            {
              "goto": "s7",
              "id": "not-all-consent",
              "label": "No — a staff member or bystander does not consent"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Do all captured parties consent to the recording?"
        },
        {
          "detail": "Allow the patient to record; note in the visit log that recording was permitted and by whom consent was given.\n\nRecord: recording permitted, date and consenting staff names logged in the office activity log",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Permit the recording and note the consent"
        },
        {
          "detail": "Recording request or incident resolved",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Recording request or incident resolved"
        },
        {
          "detail": "Politely explain that not everyone present consents to being recorded and ask the patient to stop and delete any portion capturing non-consenting staff or other patients.\n\nWhy: A calm, policy-based explanation avoids escalating what is usually a misunderstanding, not defiance.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Ask the patient to stop recording",
          "why": "A calm, policy-based explanation avoids escalating what is usually a misunderstanding, not defiance."
        },
        {
          "detail": "Does the patient stop recording?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "stops",
              "label": "Patient stops and complies"
            },
            {
              "goto": "s10",
              "id": "refuses",
              "label": "Patient refuses to stop"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the patient stop recording?"
        },
        {
          "detail": "Write the date, what was recorded or attempted, and whether consent was obtained or the recording stopped into the office incident log.\n\nRecord: date, what was recorded or attempted, whether consent was obtained or the recording stopped, logged in the office incident log",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the recording incident"
        },
        {
          "detail": "Hand off to the practice owner or compliance officer to decide whether to pause the visit, involve counsel, or continue treatment while declining further discussion until recording stops.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the practice owner or compliance officer"
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Patient asks to record the appointment, or records or films staff without consent — A patient or companion pulls out a phone to record the consultation, or begins filming in the operatory or reception area.",
      "title": "Patient asks to record the appointment, or records or films staff without consent",
      "trigger": "A patient or companion pulls out a phone to record the consultation, or begins filming in the operatory or reception area",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Workplace Violence Prevention Plan requirement, Labor Code §6401.9 (employers must have a plan for responding to workplace violence incidents)",
          "source": "California Workplace Violence Prevention Plan requirement, Labor Code §6401.9 (employers must have a plan for responding to workplace violence incidents)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=LAB&sectionNum=6401.9."
        },
        {
          "kind": "generic",
          "label": "General de-escalation script sequencing (functional equivalent — no dental-specific public statute names the exact de-escalation steps; practice policy standard) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "General de-escalation script sequencing (functional equivalent — no dental-specific public statute names the exact de-escalation steps; practice policy standard)"
          },
          "source": "General de-escalation script sequencing (functional equivalent — no dental-specific public statute names the exact de-escalation steps; practice policy standard) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "prc-011",
      "kind": "operational",
      "materials": [
        "panic button or emergency phone line",
        "incident report form",
        "de-escalation script card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "dentist",
        "all-staff",
        "ems",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the person is physically violent, brandishes a weapon, or makes a credible threat to harm someone, call 911 immediately and move staff and other patients away from the area before doing anything else.\n\nWhy: Life safety always precedes de-escalation, documentation or any office procedure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Emergency check — is there a credible threat of violence or weapon?.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Emergency check — is there a credible threat of violence or weapon?",
          "why": "Life safety always precedes de-escalation, documentation or any office procedure."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Aggressive, threatening or verbally abusive patient or companion — A patient or companion shouts, threatens staff, refuses to leave or becomes physically intimidating at the desk or in the operatory — a credible threat of violence goes to 911.",
      "title": "Aggressive, threatening or verbally abusive patient or companion",
      "trigger": "A patient or companion shouts, threatens staff, refuses to leave or becomes physically intimidating at the desk or in the operatory — a credible threat of violence goes to 911",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "No single CA statute governs a patient arriving intoxicated/impaired to a routine (non-sedation) appointment — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No single CA statute governs a patient arriving intoxicated/impaired to a routine (non-sedation) appointment — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "CA B&P §1682's own text governs simultaneous-patient monitoring ratios during moderate/deep sedation and general anesthesia (\"Dentists cannot have more than one patient undergoing moderate sedation, deep sedation, or general anesthesia ... unless each patient is being continuously monitored on a one-to-one ratio\") — it addresses multi-patient sedation safety, not a patient who arrives already intoxicated or impaired for a routine visit. The prior source, B&P §1680, is a general unprofessional-conduct catch-all, not a specific rule on impaired patients either. Neither statute, nor a search for a CA dental-board rule specific to 'patient arrives intoxicated,' surfaced a provision on point; this sits under general informed-consent/capacity doctrine, which is not codified as a single citable section for this scenario.",
            "ticket": "PROT-017",
            "was": {
              "source": "CA B&P §1682",
              "url": "https://law.justia.com/codes/california/code-bpc/division-2/chapter-4/article-4/section-1682/"
            }
          },
          "source": "No single CA statute governs a patient arriving intoxicated/impaired to a routine (non-sedation) appointment — Practice policy — no published authority governs this step."
        },
        {
          "kind": "generic",
          "label": "Informed consent requires the patient to have capacity to understand and consent to treatment (general medical/dental ethics and consent-law principle; functional equivalent applied for the capacity-assessment steps here) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Informed consent requires the patient to have capacity to understand and consent to treatment (general medical/dental ethics and consent-law principle; functional equivalent applied for the capacity-assessment steps here)"
          },
          "source": "Informed consent requires the patient to have capacity to understand and consent to treatment (general medical/dental ethics and consent-law principle; functional equivalent applied for the capacity-assessment steps here) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "prc-012",
      "kind": "operational",
      "materials": [
        "informed-consent capacity checklist",
        "safe-ride-home resource list",
        "rescheduling script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "office-manager",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note specific observations: odor of alcohol, slurred speech, unsteady gait, disorientation, or the patient's own statement about recent substance use — record what was observed, not a diagnosis.\n\nWhy: Documenting concrete observations rather than a conclusory label ('drunk') protects both the patient's dignity and the chart's accuracy.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Observe and note signs of possible impairment",
          "why": "Documenting concrete observations rather than a conclusory label ('drunk') protects both the patient's dignity and the chart's accuracy."
        },
        {
          "detail": "If the patient shows signs of a medical emergency such as unresponsiveness, difficulty breathing, or suspected overdose, call 911 immediately rather than proceeding with the capacity assessment below.\n\nWhy: A capacity-to-consent workflow assumes the patient is medically stable; a medical emergency overrides it entirely.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Emergency check — is the patient in medical distress (overdose, severe intoxication)?.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Emergency check — is the patient in medical distress (overdose, severe intoxication)?",
          "why": "A capacity-to-consent workflow assumes the patient is medically stable; a medical emergency overrides it entirely."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Patient appears intoxicated or impaired at the appointment — A patient arrives smelling of alcohol, slurring or unsteady, or admits recent drug use before treatment.",
      "title": "Patient appears intoxicated or impaired at the appointment",
      "trigger": "A patient arrives smelling of alcohol, slurring or unsteady, or admits recent drug use before treatment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations 28 CFR Part 36; CA Unruh Act (Civil Code §51)",
          "source": "ADA Title III public accommodations 28 CFR Part 36; CA Unruh Act (Civil Code §51)",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "prc-013",
      "kind": "operational",
      "materials": [
        "accessibility self-assessment checklist (prc-005)",
        "demand letter/complaint file",
        "attorney contact list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "marketing",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Whoever receives the complaint (phone, mail, email, or in person) preserves the original communication unchanged and does not respond substantively before it reaches the practice owner.\n\nWhy: An early informal response can complicate the legal posture; the practice owner and counsel should control the first substantive reply.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive and preserve the complaint or demand letter",
          "why": "An early informal response can complicate the legal posture; the practice owner and counsel should control the first substantive reply."
        },
        {
          "detail": "Is this a formal demand letter or filed lawsuit, or an informal complaint?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "formal-demand",
              "label": "Formal demand letter or filed lawsuit"
            },
            {
              "goto": "s8",
              "id": "informal-complaint",
              "label": "Informal complaint (verbal, email, review)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is this a formal demand letter or filed lawsuit, or an informal complaint?"
        },
        {
          "detail": "The practice owner routes the letter or complaint to legal counsel and does not send any written or verbal response until counsel has reviewed it.\n\nWhy: Responding to a formal ADA demand without counsel risks admissions that affect the practice's legal exposure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Route formal demands or lawsuits to legal counsel before any response.",
            "role": "practice owner, routed to legal counsel",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Route formal demands or lawsuits to legal counsel before any response",
          "why": "Responding to a formal ADA demand without counsel risks admissions that affect the practice's legal exposure."
        },
        {
          "detail": "Legal counsel reviews the allegation, advises on response strategy, and directs any settlement, remediation commitment, or formal reply.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Counsel directs the formal response"
        },
        {
          "detail": "List each identified barrier, the fix, responsible party (office-manager, marketing for web issues, contractor for physical barriers), and target completion date.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Build a remediation plan with a timeline"
        },
        {
          "detail": "Write the complaint date, classification, response given, and remediation plan with target dates into the compliance tracking log.\n\nRecord: complaint date, classification, response given, remediation plan and target dates, logged in the compliance tracking log",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the complaint and remediation plan"
        },
        {
          "detail": "Complaint logged and remediation underway",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Complaint logged and remediation underway"
        },
        {
          "detail": "The compliance officer reviews the described barrier against the practice's most recent accessibility self-assessment (prc-005) and determines whether it is a known or new gap.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Compliance officer logs and investigates the informal complaint"
        },
        {
          "detail": "Acknowledge the concern, thank them for flagging it, and state that the practice is reviewing accessibility — avoid admitting fault or promising a specific fix date before the remediation plan is scoped.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Respond to the complainant"
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "ADA accessibility complaint, demand letter or lawsuit — A patient or serial plaintiff alleges a physical, web or communication accessibility barrier.",
      "title": "ADA accessibility complaint, demand letter or lawsuit",
      "trigger": "A patient or serial plaintiff alleges a physical, web or communication accessibility barrier",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations 28 CFR Part 36; CA Unruh Act (Civil Code §51) — general public-accommodation non-discrimination floor",
          "source": "ADA Title III public accommodations 28 CFR Part 36; CA Unruh Act (Civil Code §51) — general public-accommodation non-discrimination floor",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "prc-014",
      "kind": "operational",
      "materials": [
        "non-discrimination policy statement",
        "staff support/debrief resource"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "practice-owner",
        "hr",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Staff notes exactly what the patient said — e.g. asking for a different provider because of the assigned provider's race, sex, religion, accent, or similar characteristic.\n\nWhy: The exact wording matters for distinguishing a protected-characteristic request from a legitimate clinical or scheduling preference.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the request and its stated basis",
          "why": "The exact wording matters for distinguishing a protected-characteristic request from a legitimate clinical or scheduling preference."
        },
        {
          "detail": "Is the stated basis a protected characteristic?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "is-protected",
              "label": "Yes — based on a protected characteristic"
            },
            {
              "goto": "s8",
              "id": "not-protected",
              "label": "No — legitimate reason (e.g. prior provider relationship, clinical continuity)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the stated basis a protected characteristic?"
        },
        {
          "detail": "The office manager confirms with the practice owner (or HR) that the front desk's planned response — declining to reassign on the stated ground — matches practice policy before speaking to the patient.\n\nWhy: A front-line staff member should not be the one improvising the practice's position on a discrimination-adjacent request in the moment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor confirms the response before it is delivered.",
            "role": "practice owner or HR",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Supervisor confirms the response before it is delivered",
          "why": "A front-line staff member should not be the one improvising the practice's position on a discrimination-adjacent request in the moment."
        },
        {
          "detail": "Inform the patient calmly that the practice does not reassign providers based on the stated characteristic, and offer the choice to proceed with the assigned provider or seek care elsewhere.\n\nWhy: Honoring a discriminatory reassignment request can itself expose the practice to liability toward the affected staff member and violates public-accommodation non-discrimination norms.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Decline to honor the discriminatory request",
          "why": "Honoring a discriminatory reassignment request can itself expose the practice to liability toward the affected staff member and violates public-accommodation non-discrimination norms."
        },
        {
          "detail": "Inform the provider who was the subject of the request, and hand off to HR for a support check-in and, if the patient becomes abusive, coordination with the aggressive-patient protocol (prc-011).",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the affected provider and HR"
        },
        {
          "detail": "Write the date, the stated basis for the request, the response given, and any staff support follow-up into the incident log.\n\nRecord: date, stated basis for the request, response given, and any staff support follow-up, logged in the incident log",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Request handled and logged",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Request handled and logged"
        },
        {
          "detail": "Handle the request as an ordinary scheduling preference, subject to provider availability.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Accommodate the legitimate scheduling request where possible"
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Patient requests or refuses a provider on protected-characteristic grounds — A patient refuses treatment by a provider because of race, sex, religion, accent or other protected characteristic, or requests a provider on those grounds.",
      "title": "Patient requests or refuses a provider on protected-characteristic grounds",
      "trigger": "A patient refuses treatment by a provider because of race, sex, religion, accent or other protected characteristic, or requests a provider on those grounds",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California minor consent, Family Code §6910–6929 (categories where a minor may self-consent and control disclosure of related records)",
          "source": "California minor consent, Family Code §6910–6929 (categories where a minor may self-consent and control disclosure of related records)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=FAM&sectionNum=6910."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "prc-015",
      "kind": "operational",
      "materials": [
        "minor self-consent category reference card",
        "portal access-restriction procedure in the practice management system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Is this a minor's confidentiality request or a parent's portal-access demand?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "minor-request",
              "label": "Adolescent asks that care not be shared with a parent"
            },
            {
              "goto": "s8",
              "id": "parent-demand",
              "label": "Parent demands portal access to the minor's record"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this a minor's confidentiality request or a parent's portal-access demand?"
        },
        {
          "detail": "Check the requested care against the state's minor self-consent categories (e.g. certain sensitive-care categories where a minor of qualifying age may consent without parental notice under state law).\n\nWhy: Only care that legally qualifies as minor self-consent can be withheld from a parent; routine dental care generally still requires parental consent and disclosure.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm whether the care falls in a self-consent category",
          "why": "Only care that legally qualifies as minor self-consent can be withheld from a parent; routine dental care generally still requires parental consent and disclosure."
        },
        {
          "detail": "Does the care qualify as minor self-consent under state law?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "qualifies",
              "label": "Yes — qualifies, minor controls disclosure of this episode"
            },
            {
              "goto": "s11",
              "id": "does-not-qualify",
              "label": "No — routine care, parent retains access and consent role"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the care qualify as minor self-consent under state law?"
        },
        {
          "detail": "The compliance officer confirms the self-consent category determination against the state statute list before the front desk applies the portal restriction.\n\nWhy: Applying or withholding a disclosure restriction incorrectly has legal consequences either way, so the determination gets a second, named check before it takes effect.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms the restriction before it is applied.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms the restriction before it is applied",
          "why": "Applying or withholding a disclosure restriction incorrectly has legal consequences either way, so the determination gets a second, named check before it takes effect."
        },
        {
          "detail": "In the practice management system, flag the qualifying episode so it does not surface in the parent's portal view while leaving other, non-restricted records visible as normal.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the record for restricted portal access"
        },
        {
          "detail": "Write the date, whether self-consent applied, and the portal access configuration applied into the compliance tracking log.\n\nRecord: date, whether self-consent applied, portal access configuration applied, logged in the compliance tracking log",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the confidentiality determination"
        },
        {
          "detail": "Confidentiality and portal access resolved",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confidentiality and portal access resolved"
        },
        {
          "detail": "Before granting portal access, check whether any episode in the minor's record carries a self-consent restriction flag.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check the record for a self-consent restriction flag"
        },
        {
          "detail": "Are there restricted episodes in the record?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "has-restrictions",
              "label": "Yes — restricted episodes exist"
            },
            {
              "goto": "s12",
              "id": "no-restrictions",
              "label": "No restrictions — full record"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Are there restricted episodes in the record?"
        },
        {
          "detail": "Provision the parent's portal account with access to the full record except the flagged self-consent episodes, which remain excluded from their view.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Grant portal access excluding restricted episodes"
        },
        {
          "detail": "Explain, age-appropriately, that this particular care does not meet the legal category for self-consent confidentiality and that the parent will retain normal access.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Explain to the minor that this care does not qualify for restriction"
        },
        {
          "detail": "Provision the parent's portal account with normal full access to the minor's record.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Grant full portal access"
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Adolescent confidentiality and parent portal access — A teen asks that information not be shared with a parent, or a parent demands portal access to a minor's record covered by minor-consent law.",
      "title": "Adolescent confidentiality and parent portal access",
      "trigger": "A teen asks that information not be shared with a parent, or a parent demands portal access to a minor's record covered by minor-consent law",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California mandated reporting of child abuse, Penal Code §11165.7 and §11166 (applies when a trafficking victim is a minor)",
          "source": "California mandated reporting of child abuse, Penal Code §11165.7 and §11166 (applies when a trafficking victim is a minor)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN&sectionNum=11166."
        },
        {
          "kind": "statute",
          "label": "California elder and dependent adult abuse mandated reporting, Welfare & Institutions Code §15630 (applies when a trafficking victim is also an elder or dependent adult)",
          "source": "California elder and dependent adult abuse mandated reporting, Welfare & Institutions Code §15630 (applies when a trafficking victim is also an elder or dependent adult)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=WIC&sectionNum=15630."
        },
        {
          "kind": "generic",
          "label": "General trafficking-indicator awareness and private-interview technique (functional equivalent — no dental-specific trafficking statute; adult-victim indicator response is practice policy standard) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "General trafficking-indicator awareness and private-interview technique (functional equivalent — no dental-specific trafficking statute; adult-victim indicator response is practice policy standard)"
          },
          "source": "General trafficking-indicator awareness and private-interview technique (functional equivalent — no dental-specific trafficking statute; adult-victim indicator response is practice policy standard) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "prc-016",
      "kind": "operational",
      "materials": [
        "national human trafficking hotline card",
        "private-interview room protocol",
        "indicator checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Note specific observations: companion answers for the patient, patient appears fearful or gives scripted/rehearsed answers, patient lacks control of ID or phone, signs of untreated injury or neglect, inconsistent story.\n\nWhy: No single sign confirms trafficking; the pattern across several indicators is what warrants a private-interview attempt.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Observe and note trafficking indicators",
          "why": "No single sign confirms trafficking; the pattern across several indicators is what warrants a private-interview attempt."
        },
        {
          "detail": "If the patient appears to be in immediate physical danger or the companion becomes threatening, call 911 rather than attempting a private interview.\n\nWhy: An unsafe attempt to separate the patient from a dangerous companion can escalate risk to staff and the patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Emergency check — is the patient in immediate danger?.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Emergency check — is the patient in immediate danger?",
          "why": "An unsafe attempt to separate the patient from a dangerous companion can escalate risk to staff and the patient."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Suspected human trafficking indicators response — A patient is accompanied by someone who answers for them, lacks ID or control of documents, shows fear or scripted answers, and presents with untreated injuries.",
      "title": "Suspected human trafficking indicators response",
      "trigger": "A patient is accompanied by someone who answers for them, lacks ID or control of documents, shows fear or scripted answers, and presents with untreated injuries",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations 28 CFR Part 36; CA Unruh Act (Civil Code §51) — a business may set reasonable, content-neutral, safety-based conditions of service",
          "source": "ADA Title III public accommodations 28 CFR Part 36; CA Unruh Act (Civil Code §51) — a business may set reasonable, content-neutral, safety-based conditions of service",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        },
        {
          "kind": "generic",
          "label": "State and local firearms-in-private-facility law (open-carry rules, concealed-carry permit recognition, and private-property posting requirements to exclude weapons) varies by jurisdiction; the office's response here is a generic private-business safety policy, not itself a public compliance mandate — confirm state and local specifics with counsel before adopting a posted policy — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "State and local firearms-in-private-facility law (open-carry rules, concealed-carry permit recognition, and private-property posting requirements to exclude weapons) varies by jurisdiction; the office's response here is a generic private-business safety policy, not itself a public compliance mandate — confirm state and local specifics with counsel before adopting a posted policy"
          },
          "source": "State and local firearms-in-private-facility law (open-carry rules, concealed-carry permit recognition, and private-property posting requirements to exclude weapons) varies by jurisdiction; the office's response here is a generic private-business safety policy, not itself a public compliance mandate — confirm state and local specifics with counsel before adopting a posted policy — Practice policy — no published authority governs this step."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "prc-017",
      "kind": "operational",
      "materials": [
        "posted no-weapons policy sign (if the practice has adopted one)",
        "office incident log",
        "local law-enforcement non-emergency contact card"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Front desk or whoever first observes the weapon quickly judges the situation before approaching anyone: if the weapon is drawn, the person is threatening staff or patients, or behavior is escalating, call 911 immediately rather than continuing to the routine policy conversation below.\n\nWhy: Whether this is a security emergency or a calm policy conversation changes the entire next step, so the branch has to happen before any approach.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Emergency check — is there an active threat? Call 911 first if so..",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Emergency check — is there an active threat? Call 911 first if so.",
          "why": "Whether this is a security emergency or a calm policy conversation changes the entire next step, so the branch has to happen before any approach."
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Patient or visitor carrying a visible firearm or weapon — A patient or companion is seen with a firearm or knife in the office without threatening behavior.",
      "title": "Patient or visitor carrying a visible firearm or weapon",
      "trigger": "A patient or companion is seen with a firearm or knife in the office without threatening behavior",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Privacy Rule — permitted disclosures to correctional institutions and law-enforcement officials having lawful custody of an inmate or other individual, 45 CFR §164.512(k)(5)",
          "source": "HIPAA Privacy Rule — permitted disclosures to correctional institutions and law-enforcement officials having lawful custody of an inmate or other individual, 45 CFR §164.512(k)(5)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.512"
        },
        {
          "kind": "regulation",
          "label": "ADA Title III public accommodations 28 CFR Part 36 — patient dignity and access baseline, applied within facility security constraints",
          "source": "ADA Title III public accommodations 28 CFR Part 36 — patient dignity and access baseline, applied within facility security constraints",
          "url": "https://www.ecfr.gov/current/title-28/part-36"
        },
        {
          "kind": "generic",
          "label": "Restraint, escort staffing, and custody-visit procedures are set by the individual correctional or law-enforcement agency, not by a single public statute; treat the escorting agency's own policy as authoritative for security handling — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Restraint, escort staffing, and custody-visit procedures are set by the individual correctional or law-enforcement agency, not by a single public statute; treat the escorting agency's own policy as authoritative for security handling"
          },
          "source": "Restraint, escort staffing, and custody-visit procedures are set by the individual correctional or law-enforcement agency, not by a single public statute; treat the escorting agency's own policy as authoritative for security handling — Practice policy — no published authority governs this step."
        }
      ],
      "class": "patient-rights-mandated-reporting",
      "department": "compliance",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "prc-018",
      "kind": "operational",
      "materials": [
        "custody visit intake/referral form",
        "facility billing authorization form",
        "restraint-removal authorization log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the appointment is a scheduled custody visit and check the escorting agency and officer identification against the referral paperwork before anyone is brought in.\n\nWhy: Confirming legitimacy before entry protects both patient safety and the office's chain of custody for the visit.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify the custody appointment and escort",
          "why": "Confirming legitimacy before entry protects both patient safety and the office's chain of custody for the visit."
        },
        {
          "detail": "Check: a private entrance/waiting arrangement if available, the facility's restraint policy for this visit, whether the officer plans to remain in the room, and the facility's expected billing authorization method.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm visit logistics"
        },
        {
          "detail": "Obtain the patient's own informed consent (or refusal) for treatment directly from the patient; being in custody does not remove a patient's right to consent to or refuse non-emergency dental care.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain the patient's own informed consent.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Obtain the patient's own informed consent"
        },
        {
          "detail": "Arrange the treatment area to accommodate restraint equipment or mobility needs per the facility's stated policy, and confirm officer positioning that balances the facility's security requirement with the patient's privacy.\n\nWhy: Getting the room setup right before the patient is brought in avoids mid-visit delays and awkward renegotiation in front of the patient.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Set up the treatment area for the visit",
          "why": "Getting the room setup right before the patient is brought in avoids mid-visit delays and awkward renegotiation in front of the patient."
        },
        {
          "detail": "Dentist and officer agree on positioning before the exam begins.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "line-of-sight",
              "label": "Officer remains in direct line of sight per the facility's standard security policy"
            },
            {
              "advised": false,
              "goto": "s11",
              "id": "restraint-removal",
              "label": "Officer is asked to loosen or remove restraints for the procedure"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide officer positioning during the exam"
        },
        {
          "detail": "Provide treatment as clinically indicated, treating the patient with the same standard of care and dignity as any other patient in the practice.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Provide treatment"
        },
        {
          "detail": "Share with the escorting officer only what is necessary for safe custody and transport; do not disclose clinical details beyond that, absent the patient's own authorization or a specific legal requirement.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Limit information shared with the escort to the minimum necessary.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Limit information shared with the escort to the minimum necessary"
        },
        {
          "detail": "Confirm the billing or payment authorization from the custodial facility — purchase order, agency billing account, or facility-provided coverage — before or immediately after the visit.\n\nWhy: Treatment already provided under the consent gate above is never withheld or delayed pending confirmation of the facility's billing authorization; billing is confirmed in parallel with, never as a precondition of, care already given.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm billing authorization",
          "why": "Treatment already provided under the consent gate above is never withheld or delayed pending confirmation of the facility's billing authorization; billing is confirmed in parallel with, never as a precondition of, care already given."
        },
        {
          "detail": "Document the custodial status, escorting agency and officer, restraint handling, consent obtained, and any information disclosed to the officer, in the chart per standard documentation practice.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the custody visit"
        },
        {
          "detail": "Protocol complete",
          "id": "s10",
          "kind": "step",
          "title": "Protocol complete"
        },
        {
          "detail": "Do not loosen or remove restraints without the escorting officer's explicit authorization and the facility's own sign-off; this decision belongs to the custodial agency, not the dental office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Do not remove restraints without authorization.",
            "role": "escorting officer's supervisor / facility policy",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "office-manager",
          "title": "Do not remove restraints without authorization"
        }
      ],
      "subclass": "patient-rights-consent-access-and-mandated-reporting",
      "summary": "Patient in custody with a law-enforcement or corrections escort — A jail or detention facility schedules an inmate with an officer present, possibly restrained.",
      "title": "Patient in custody with a law-enforcement or corrections escort",
      "trigger": "A jail or detention facility schedules an inmate with an officer present, possibly restrained",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (in-repo image-selection table)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (in-repo image-selection table)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "rad-001",
      "kind": "clinical",
      "materials": [
        "updated medical/dental history",
        "prior radiographs or imaging history",
        "caries-risk assessment notes"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Assistant or hygienist reviews caries history, periodontal status, symptoms, prior treatment, and pulls the date and type of the most recent radiographs on file.\n\nWhy: Selection criteria are risk- and history-based, not calendar-based — imaging without a documented reason is the most common overexposure finding.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Gather dental and medical history relevant to imaging need",
          "why": "Selection criteria are risk- and history-based, not calendar-based — imaging without a documented reason is the most common overexposure finding."
        },
        {
          "detail": "Classify caries/periodontal risk and visit type",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "low",
              "label": "Low-risk recall, films current within interval"
            },
            {
              "goto": "s3",
              "id": "high",
              "label": "High-risk recall, new complaint, or no recent films"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "hygienist",
          "title": "Classify caries/periodontal risk and visit type"
        },
        {
          "detail": "Propose the minimum image set that answers the clinical question: bitewings for interproximal caries, periapicals for a specific tooth, panoramic for a full-arch survey, per the FDA/ADA selection criteria table.\n\nWhy: ALARA (as low as reasonably achievable) means proposing the smallest set that answers the question, not the largest set available.",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist or assistant proposes an imaging set",
          "why": "ALARA (as low as reasonably achievable) means proposing the smallest set that answers the question, not the largest set available."
        },
        {
          "detail": "The dentist confirms or modifies the proposed image set and signs the order before exposure. A non-dentist may propose imaging but may not be the final prescriber.\n\nWhy: Radiographic prescription is a licensed clinical judgment call, not a delegable technical task.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and prescribes the final imaging order.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and prescribes the final imaging order",
          "why": "Radiographic prescription is a licensed clinical judgment call, not a delegable technical task."
        },
        {
          "detail": "Chart the images ordered, the clinical indication, and the risk tier used to justify the order.\n\nRecord: imaging order + rationale in the patient chart",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Document the imaging rationale in the chart"
        },
        {
          "detail": "Assistant or hygienist proceeds to the matching acquisition protocol (bitewing, periapical, full-mouth series, panoramic, or CBCT) per the prescribed order.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off the prescribed order to the operator taking the images"
        },
        {
          "detail": "Imaging order complete",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Imaging order complete"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Radiograph selection — dentist prescription based on history, risk and visit type (hygienist proposes, dentist prescribes) — A patient is due for imaging or presents with a new complaint.",
      "title": "Radiograph selection — dentist prescription based on history, risk and visit type (hygienist proposes, dentist prescribes)",
      "trigger": "A patient is due for imaging or presents with a new complaint",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.2-2.3 (in-repo radiation safety and technique)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.2-2.3 (in-repo radiation safety and technique)"
        },
        {
          "kind": "open_standard",
          "label": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "source": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "url": "https://ncrponline.org/publications/reports/ncrp-report-177/"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 8,
      "frequency": "per-patient",
      "id": "rad-002",
      "kind": "clinical",
      "materials": [
        "digital sensor or phosphor plate with barrier",
        "bitewing tab or holder",
        "lead apron and thyroid collar"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Drape the apron and thyroid collar on the patient before any sensor placement, for every patient regardless of age.\n\nWhy: Shielding the patient is the baseline radiation-safety control and is done before positioning, not after.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Place lead apron and thyroid collar",
          "why": "Shielding the patient is the baseline radiation-safety control and is done before positioning, not after."
        },
        {
          "detail": "Cover the sensor or phosphor plate with a single-use barrier sleeve before it enters the mouth; discard after each patient.\n\nWhy: The sensor cannot be sterilized between patients — the barrier is the infection-control control point.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Place a fresh disposable barrier on the sensor or plate",
          "why": "The sensor cannot be sterilized between patients — the barrier is the infection-control control point."
        },
        {
          "detail": "Center the sensor over the interproximal contacts of the area being imaged, using a bitewing tab or holder so the patient bites gently to stabilize it; align the beam perpendicular to the sensor.\n\nWhy: Open (non-overlapped) interproximal contacts are the diagnostic requirement for detecting proximal caries — poor angulation is the leading cause of retakes.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Position the sensor with a bitewing tab or holder",
          "why": "Open (non-overlapped) interproximal contacts are the diagnostic requirement for detecting proximal caries — poor angulation is the leading cause of retakes."
        },
        {
          "detail": "Use the lowest workable exposure setting for the digital sensor type per equipment settings, confirm the patient and operator are positioned correctly, then expose.\n\nWhy: Digital sensors require substantially less exposure than film; using film-era settings over-exposes the patient.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Set exposure factors for the sensor and expose",
          "why": "Digital sensors require substantially less exposure than film; using film-era settings over-exposes the patient."
        },
        {
          "detail": "Review the image for diagnostic quality",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "acceptable",
              "label": "Contacts open, no cone-cut, diagnostic quality"
            },
            {
              "goto": "s8",
              "id": "retake",
              "label": "Overlapped contacts, cone-cut, or motion — retake needed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Review the image for diagnostic quality"
        },
        {
          "detail": "Record the final accepted image in the chart and log any retakes with the reason, per the retake-and-QA protocol (rad-018).\n\nRecord: final image in chart; retake count and reason in the retake log",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Log the image and any retakes in the retake QA log"
        },
        {
          "detail": "Bitewing acquisition complete",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Bitewing acquisition complete"
        },
        {
          "detail": "Name the error (vertical angulation, horizontal angulation, cone-cut, patient movement, sensor placement) so the correction is deliberate rather than a repeat of the same mistake.\n\nWhy: An unexamined retake risks repeating the same error and doubling the patient's exposure for no diagnostic gain.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Identify the specific positioning error before retaking",
          "why": "An unexamined retake risks repeating the same error and doubling the patient's exposure for no diagnostic gain."
        },
        {
          "detail": "Is this the first retake attempt for this view this visit, or a repeat?",
          "forks": [
            {
              "advised": true,
              "goto": "s1",
              "id": "first-retake",
              "label": "First retake attempt for this view this visit"
            },
            {
              "goto": "s10",
              "id": "repeat-retake",
              "label": "Second or later retake attempt for the same view this visit"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "assistant",
          "title": "Is this the first retake attempt for this view this visit, or a repeat?"
        },
        {
          "detail": "The dentist reviews the prior positioning attempts and either identifies a different technique (holder change, different sensor size, alternate angulation) or authorizes one additional attempt before any further exposure is taken.\n\nWhy: Repeated retakes without a checkpoint work against ALARA; a second failure gets a second set of eyes before the patient is exposed again.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews before any further attempt",
          "why": "Repeated retakes without a checkpoint work against ALARA; a second failure gets a second set of eyes before the patient is exposed again."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Bitewing technique with positioning and retake criteria — Bitewings are prescribed.",
      "title": "Bitewing technique with positioning and retake criteria",
      "trigger": "Bitewings are prescribed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.3 Periapical Technique (Paralleling)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.3 Periapical Technique (Paralleling)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 6,
      "frequency": "per-use",
      "id": "rad-003",
      "kind": "clinical",
      "materials": [
        "digital sensor or phosphor plate with barrier",
        "film/sensor holder (XCP-type positioning device)",
        "lead apron and thyroid collar"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Verify the tooth number(s) against the prescribed order before setup — imaging the wrong tooth means repeating the exposure.\n\nWhy: Periapicals are targeted at a specific tooth, unlike a bitewing survey; wrong-tooth imaging is a preventable retake.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the specific tooth or teeth requiring the periapical image",
          "why": "Periapicals are targeted at a specific tooth, unlike a bitewing survey; wrong-tooth imaging is a preventable retake."
        },
        {
          "detail": "Place lead apron and thyroid collar, then place a fresh disposable barrier on the sensor or phosphor plate.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Shield the patient and barrier the sensor"
        },
        {
          "detail": "Using a holder (XCP-type positioning device), position the receptor parallel to the tooth's long axis, away from the tooth surface, with the patient biting gently to stabilize it without sensor movement.\n\nWhy: The paralleling technique minimizes image distortion compared to the older bisecting-angle technique, giving a more accurate length and root/bone relationship.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Place the sensor/film parallel to the long axis of the tooth",
          "why": "The paralleling technique minimizes image distortion compared to the older bisecting-angle technique, giving a more accurate length and root/bone relationship."
        },
        {
          "detail": "Aim the central x-ray beam perpendicular to the long axis of the tooth and the plane of the receptor, using the holder's aiming ring as a guide.\n\nWhy: Misalignment here produces foreshortening or elongation, the two most common periapical geometric errors.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Align the central beam perpendicular to both tooth and receptor",
          "why": "Misalignment here produces foreshortening or elongation, the two most common periapical geometric errors."
        },
        {
          "detail": "Use manufacturer-recommended exposure settings for the digital sensor (typically the lowest workable setting), confirm patient is still and stable, then expose.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Set exposure per receptor type and expose"
        },
        {
          "detail": "Does the image show the full root apex plus surrounding bone?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes",
              "label": "Full apex and periapical bone visible, no distortion"
            },
            {
              "goto": "s9",
              "id": "no",
              "label": "Apex cut off, cone-cut, or distorted — retake needed"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the image show the full root apex plus surrounding bone?"
        },
        {
          "detail": "Record the accepted image against the tooth number in the chart; log any retakes with reason per the retake QA protocol.\n\nRecord: final image + tooth number in chart; retakes in QA log",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the accepted image and any retakes"
        },
        {
          "detail": "Periapical acquisition complete",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Periapical acquisition complete"
        },
        {
          "detail": "Adjust holder angulation to correct for the specific error observed (apex cut off usually means the beam angle or sensor position needs raising/lowering), then re-shield and re-expose.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Reposition using the holder and repeat"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Periapical paralleling technique — A periapical image is prescribed for a specific tooth.",
      "title": "Periapical paralleling technique",
      "trigger": "A periapical image is prescribed for a specific tooth",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (baseline exam recommendation for new adult patients)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (baseline exam recommendation for new adult patients)"
        },
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "rad-004",
      "kind": "clinical",
      "materials": [
        "digital sensors or phosphor plates with barriers",
        "periapical and bitewing holders",
        "lead apron and thyroid collar",
        "full-mouth series mounting template (digital or physical)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Verify against rad-001's documented order that a full baseline series (not a lesser set) was the dentist's prescription for this visit.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the full-mouth series is indicated per the prescribed order"
        },
        {
          "detail": "Drape apron and thyroid collar before the first exposure of the series.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Place lead apron and thyroid collar"
        },
        {
          "detail": "Follow the periapical paralleling technique (rad-003) for the anterior series (typically 6 images: maxillary and mandibular incisors and canines).",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Acquire anterior periapicals first"
        },
        {
          "detail": "Follow the periapical paralleling technique for each posterior quadrant (premolars, molars) in a consistent order so no area is missed.\n\nWhy: A consistent quadrant order is the simplest control against an incomplete series that isn't caught until mounting.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Acquire posterior periapicals by quadrant",
          "why": "A consistent quadrant order is the simplest control against an incomplete series that isn't caught until mounting."
        },
        {
          "detail": "Follow the bitewing technique (rad-002) for left and right posterior bitewings to complete the interproximal survey.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Acquire bitewings"
        },
        {
          "detail": "Check every position in the full-mouth series template is filled with a diagnostic-quality image: anteriors present, all four posterior quadrants present, both bitewings present, no gaps.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Mount the series and verify completeness against the template"
        },
        {
          "detail": "Is the series complete and diagnostic?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "complete",
              "label": "All positions filled, diagnostic quality"
            },
            {
              "goto": "s10",
              "id": "incomplete",
              "label": "One or more positions missing or non-diagnostic"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the series complete and diagnostic?"
        },
        {
          "detail": "Record the full-mouth series as complete with the acquisition date; note in the patient chart for future recall-interval reference.\n\nRecord: series completion date and image count in the chart",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Log series completion in the chart"
        },
        {
          "detail": "Full-mouth series complete",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Full-mouth series complete"
        },
        {
          "detail": "Re-shield if needed, and retake only the specific position(s) that failed — do not repeat the full series.\n\nWhy: Retaking the whole series for one missed image needlessly doubles exposure for the already-diagnostic images.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Identify and retake only the missing or non-diagnostic image(s)",
          "why": "Retaking the whole series for one missed image needlessly doubles exposure for the already-diagnostic images."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Full-mouth series acquisition sequence — A new adult patient without recent films, or a high-risk re-baseline.",
      "title": "Full-mouth series acquisition sequence",
      "trigger": "A new adult patient without recent films, or a high-risk re-baseline",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.4 Panoramic Imaging",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.4 Panoramic Imaging"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 7,
      "frequency": "per-use",
      "id": "rad-005",
      "kind": "clinical",
      "materials": [
        "panoramic unit",
        "bite peg",
        "lead apron without thyroid collar (per unit manufacturer guidance) or thyroid-shield-compatible apron"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Have the patient remove jewelry (earrings, necklaces, piercings in the imaging field), glasses, hearing aids, and any removable dental prosthetics or partials.\n\nWhy: Any of these items superimposes an artifact on the image, most commonly causing a retake.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Remove all radiopaque items before positioning",
          "why": "Any of these items superimposes an artifact on the image, most commonly causing a retake."
        },
        {
          "detail": "Have the patient bite gently on the bite peg, rest the chin on the chin rest, align the Frankfurt horizontal plane parallel to the floor, and keep the spine straight (not slouched) to avoid a ghost shadow on the image.\n\nWhy: A slouched spine or tipped Frankfurt plane are the two most common positioning errors and both distort the resulting image in ways that can mimic or obscure pathology.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Position the patient in the unit",
          "why": "A slouched spine or tipped Frankfurt plane are the two most common positioning errors and both distort the resulting image in ways that can mimic or obscure pathology."
        },
        {
          "detail": "Use the unit's light guides to confirm the patient's midline is centered and the anterior teeth are engaged on the bite peg edge-to-edge.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm midsagittal plane alignment and bite peg engagement"
        },
        {
          "detail": "Select exposure factors appropriate to patient size (adult vs. child settings), confirm the patient is stable and instructed not to move or swallow during the rotation, then expose.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Set exposure and expose"
        },
        {
          "detail": "Screen the image for common positioning errors",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "clean",
              "label": "No jewelry artifact, correct occlusal plane, spine straight, full anatomy captured"
            },
            {
              "goto": "s9",
              "id": "error-found",
              "label": "Artifact, tipped occlusal plane, spine curvature ('smile'/'frown' shadow), or cut-off anatomy"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Screen the image for common positioning errors"
        },
        {
          "detail": "Does the diagnostic question require periapical-level detail?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pano-sufficient",
              "label": "Panoramic detail is sufficient for the indication (survey, third molars, growth)"
            },
            {
              "goto": "s10",
              "id": "needs-periapical",
              "label": "Fine periapical detail is needed (endodontic, subtle periapical lesion)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Does the diagnostic question require periapical-level detail?"
        },
        {
          "detail": "Record acquisition date and indication in the chart.\n\nRecord: panoramic image + indication in the chart",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the panoramic image in the chart"
        },
        {
          "detail": "Panoramic acquisition complete",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Panoramic acquisition complete"
        },
        {
          "detail": "Identify the specific error (retained item, chin position too high/low, slouching) and correct that factor specifically before repeating positioning.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Correct the specific error and reposition"
        },
        {
          "detail": "Note in the chart that the panoramic does not substitute for periapical detail on the area in question, and route back to the dentist for a supplemental order.\n\nWhy: A panoramic is a survey image, not a substitute for periapical detail where fine root or periapical detail is the diagnostic question.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Flag for the dentist that a supplemental periapical may be needed",
          "why": "A panoramic is a survey image, not a substitute for periapical detail where fine root or periapical detail is the diagnostic question."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Panoramic imaging — patient prep, positioning, common error recognition — A panoramic image is prescribed for third molars, growth, pathology or implant screening.",
      "title": "Panoramic imaging — patient prep, positioning, common error recognition",
      "trigger": "A panoramic image is prescribed for third molars, growth, pathology or implant screening",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "regulation",
          "label": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30-1020.33",
          "source": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30-1020.33",
          "url": "https://www.ecfr.gov/current/title-21/part-1020"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rad-006",
      "kind": "clinical",
      "materials": [
        "CBCT unit",
        "lead apron and thyroid collar (unit-permitting)",
        "prior 2D imaging for comparison"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The dentist records why 2D imaging is insufficient for this clinical question (implant site planning, complex endodontic anatomy, suspected pathology extent) before a CBCT is ordered.\n\nWhy: CBCT delivers substantially higher dose than 2D imaging; ALARA requires a documented reason it is the minimum necessary study, not a default upgrade.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist documents clinical justification before ordering CBCT.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist documents clinical justification before ordering CBCT",
          "why": "CBCT delivers substantially higher dose than 2D imaging; ALARA requires a documented reason it is the minimum necessary study, not a default upgrade."
        },
        {
          "detail": "Select the smallest field of view (FOV) that answers the clinical question",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "limited",
              "label": "Limited/focused FOV covering only the region of interest"
            },
            {
              "goto": "s3",
              "id": "large",
              "label": "Large/full-arch FOV needed (e.g. multiple implant sites, complex pathology extent)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Select the smallest field of view (FOV) that answers the clinical question"
        },
        {
          "detail": "Remove radiopaque items in the field, shield per unit manufacturer guidance (some CBCT units restrict thyroid collar use — follow the unit's instructions), and position per the unit's protocol for the selected FOV.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Prepare and position the patient"
        },
        {
          "detail": "Select exposure parameters matched to the FOV size and patient size, confirm the patient is stable, and acquire.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Acquire the scan"
        },
        {
          "detail": "Who is responsible for reading the full captured volume?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "prescriber-reads",
              "label": "Prescribing dentist reads the entire volume, including anatomy outside the region of interest"
            },
            {
              "goto": "s9",
              "id": "refer-out",
              "label": "Volume extends beyond the prescribing dentist's scope of interpretation — refer to a specialist for full-volume read"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Who is responsible for reading the full captured volume?"
        },
        {
          "detail": "Whoever reads the volume documents findings across all captured anatomy, not only the region of primary interest, and notes any incidental findings for follow-up per rad-010.\n\nWhy: A CBCT volume routinely captures anatomy well beyond the region of interest (airway, adjacent sinuses, opposite-arch structures); an unread portion of the volume is an unaddressed liability and a missed-diagnosis risk.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Review and document findings across the entire captured volume",
          "why": "A CBCT volume routinely captures anatomy well beyond the region of interest (airway, adjacent sinuses, opposite-arch structures); an unread portion of the volume is an unaddressed liability and a missed-diagnosis risk."
        },
        {
          "detail": "Record justification, FOV size, acquisition date, and the interpretation (or the referral and its outcome) in the chart.\n\nRecord: justification, FOV, interpretation, and referral outcome (if any) in the chart",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Log the scan, FOV, justification and interpretation in the chart"
        },
        {
          "detail": "CBCT acquisition and interpretation responsibility resolved",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "CBCT acquisition and interpretation responsibility resolved"
        },
        {
          "detail": "Transmit the complete captured volume (not a cropped region) to the reading specialist, with the clinical question stated.\n\nWhy: Ownership of the full volume never transfers away silently — either the prescribing dentist reads all captured anatomy or a named specialist explicitly takes that responsibility.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Send the full volume to a specialist for interpretation",
          "why": "Ownership of the full volume never transfers away silently — either the prescribing dentist reads all captured anatomy or a named specialist explicitly takes that responsibility."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "CBCT justification, field-of-view limitation, acquisition and full-volume interpretation responsibility — 3D imaging is considered for implants, endodontics or pathology.",
      "title": "CBCT justification, field-of-view limitation, acquisition and full-volume interpretation responsibility",
      "trigger": "3D imaging is considered for implants, endodontics or pathology",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (new child, primary-teeth baseline row)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (new child, primary-teeth baseline row)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 8,
      "frequency": "per-patient",
      "id": "rad-007",
      "kind": "clinical",
      "materials": [
        "pediatric-sized sensors/holders where available",
        "lead apron and thyroid collar",
        "pregnancy status screening question on intake"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Ask every patient of reproductive age whether they are or may be pregnant as part of imaging intake; confirm patient age for anyone appearing to be a minor.\n\nWhy: Necessity review changes for both populations, and the screening question has to happen before imaging is set up, not after.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Screen for pregnancy status or confirm pediatric age at intake",
          "why": "Necessity review changes for both populations, and the screening question has to happen before imaging is set up, not after."
        },
        {
          "detail": "The dentist confirms the imaging is clinically necessary now (active pain, infection, or a finding that changes treatment) rather than routine/elective, weighing the benefit against the exposure for this patient.\n\nWhy: Necessity review — not blanket avoidance — is the standard: dental radiography at diagnostic doses with shielding is not a reason to withhold needed diagnosis, but elective imaging should be deferred where reasonable.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews clinical necessity given the population.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews clinical necessity given the population",
          "why": "Necessity review — not blanket avoidance — is the standard: dental radiography at diagnostic doses with shielding is not a reason to withhold needed diagnosis, but elective imaging should be deferred where reasonable."
        },
        {
          "detail": "Is imaging necessary now?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "necessary",
              "label": "Yes — active symptom or finding requires imaging now"
            },
            {
              "goto": "s9",
              "id": "defer",
              "label": "No — can reasonably be deferred (e.g. routine recall bitewings during pregnancy)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is imaging necessary now?"
        },
        {
          "detail": "For a pregnant patient, explain the shielding used and that necessary dental imaging with shielding carries minimal fetal exposure per the public floor guidance; for a minor, confirm guardian consent per the patient-rights/consent protocol. Document the discussion.\n\nWhy: Consent for imaging in these populations is a documented conversation, not an assumption — the patient or guardian needs the necessity reasoning to consent meaningfully.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Discuss and document consent for the specific patient population.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Discuss and document consent for the specific patient population",
          "why": "Consent for imaging in these populations is a documented conversation, not an assumption — the patient or guardian needs the necessity reasoning to consent meaningfully."
        },
        {
          "detail": "For a child, use pediatric-sized sensors/holders and the lowest workable pediatric exposure setting; for any patient, apply full lead apron and thyroid collar shielding per rad-002/rad-003 technique.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Apply population-appropriate technique modifications"
        },
        {
          "detail": "Route to the specific acquisition protocol (bitewing, periapical, panoramic) needed — do not default to a full-mouth series when a targeted image answers the question.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Acquire only the minimum image set needed to answer the clinical question"
        },
        {
          "detail": "Record the images taken, the documented necessity, and the consent discussion in the chart.\n\nRecord: images + necessity rationale + consent note in the chart",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the images, necessity rationale and consent"
        },
        {
          "detail": "Pediatric/pregnancy imaging pathway complete",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Pediatric/pregnancy imaging pathway complete"
        },
        {
          "detail": "Document the deferral decision and when imaging will be reconsidered (e.g. postpartum, next scheduled recall).\n\nRecord: deferral decision + follow-up interval in the chart",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Log the deferral and follow-up interval"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Imaging modification, necessity review and consent for children and pregnant patients — Imaging is needed for a child, or for a patient who is or may be pregnant.",
      "title": "Imaging modification, necessity review and consent for children and pregnant patients",
      "trigger": "Imaging is needed for a child, or for a patient who is or may be pregnant",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "generic",
          "label": "Repo-original gag-reflex and patient-comfort technique guidance (no specific in-repo textual source — general dental assisting practice, not derived from a public standard) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Repo-original gag-reflex and patient-comfort technique guidance (no specific in-repo textual source — general dental assisting practice, not derived from a public standard)"
          },
          "source": "Repo-original gag-reflex and patient-comfort technique guidance (no specific in-repo textual source — general dental assisting practice, not derived from a public standard) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "rad-008",
      "kind": "clinical",
      "materials": [
        "extra-comfort sensor holders (smaller sizes)",
        "topical anesthetic gel for the gag reflex zone (if practice-approved)",
        "panoramic unit as a fallback"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ask the patient and observe which sensor placements (posterior maxillary especially) trigger the reflex, and whether it is anxiety-driven or purely reflexive.\n\nWhy: The technique modification needed differs depending on whether the trigger is anxiety, sensor size/placement, or a strong physical reflex.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Assess where in the mouth the gag reflex triggers",
          "why": "The technique modification needed differs depending on whether the trigger is anxiety, sensor size/placement, or a strong physical reflex."
        },
        {
          "detail": "Try breathing coaching (nasal breathing), distraction, a smaller sensor size, adjusted placement further from the trigger zone, and reassurance about the brief duration of the exposure.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Apply first-line comfort and technique measures"
        },
        {
          "detail": "Did first-line measures allow a diagnostic image?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "success",
              "label": "Yes — image obtained"
            },
            {
              "goto": "s6",
              "id": "still-intolerant",
              "label": "No — patient still cannot tolerate sensor placement"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Did first-line measures allow a diagnostic image?"
        },
        {
          "detail": "Record which comfort measures or alternative strategy worked (or didn't), so the next visit's operator does not repeat failed approaches.\n\nRecord: successful/failed technique notes in the chart for future visits",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Log the technique used and outcome"
        },
        {
          "detail": "Imaging attempt resolved",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Imaging attempt resolved"
        },
        {
          "detail": "Choose the next escalation step",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "topical",
              "label": "Apply topical anesthetic gel to the gag-trigger zone (if practice-approved) and retry"
            },
            {
              "goto": "s7",
              "id": "extraoral-fallback",
              "label": "Move to an extraoral-only strategy (panoramic in place of the intraoral series)"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Choose the next escalation step"
        },
        {
          "detail": "Follow the panoramic imaging protocol (rad-005) to obtain a survey image that does not require intraoral sensor placement.\n\nWhy: A panoramic cannot fully substitute for periapical/bitewing detail (see rad-005), so this is a documented compromise, not a silent substitution.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Acquire a panoramic image as the extraoral alternative",
          "why": "A panoramic cannot fully substitute for periapical/bitewing detail (see rad-005), so this is a documented compromise, not a silent substitution."
        },
        {
          "detail": "Note that periapical/bitewing detail could not be obtained and why, so the dentist can weigh diagnostic limitations and decide whether a later attempt or a specialist referral is needed.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Flag the incomplete intraoral series to the dentist"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Gagging or intolerant patient — alternative imaging strategies — A patient cannot tolerate intraoral sensor placement.",
      "title": "Gagging or intolerant patient — alternative imaging strategies",
      "trigger": "A patient cannot tolerate intraoral sensor placement",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "open_standard",
          "label": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "source": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "url": "https://ncrponline.org/publications/reports/ncrp-report-177/"
        },
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "rad-009",
      "kind": "clinical",
      "materials": [
        "wall-mounted or handheld x-ray unit with exposure switch on a cord or wireless trigger",
        "lead or lead-equivalent apron and thyroid collar",
        "positioning barrier or doorway with lead-lined wall",
        "posted operator distance/position diagram",
        "annual safety policy document"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What is triggering this workflow — a routine exposure, or the annual policy review?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "per-exposure",
              "label": "About to take a radiographic exposure (routine per-exposure operator position, distance and shielding)"
            },
            {
              "goto": "s7",
              "id": "annual-review",
              "label": "The annual radiation-safety policy review is due"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "assistant",
          "title": "What is triggering this workflow — a routine exposure, or the annual policy review?"
        },
        {
          "detail": "Before every exposure, the operator stands at least 6 feet from the x-ray tube and the patient, or steps fully behind a lead-lined wall or protective barrier, positioned at roughly a 90–135 degree angle to the beam if no barrier is available.\n\nWhy: ALARA (as low as reasonably achievable) is the governing radiation-safety principle: distance and shielding are the cheapest, most reliable dose reductions available to the operator.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the operator distance and barrier plan before exposing",
          "why": "ALARA (as low as reasonably achievable) is the governing radiation-safety principle: distance and shielding are the cheapest, most reliable dose reductions available to the operator."
        },
        {
          "detail": "The operator never stabilizes the tube head by hand during exposure, and never holds a film, phosphor plate or sensor in a patient's mouth during exposure — a holding device or the patient's own hand is used instead.\n\nWhy: Hand-holding the tube or the image receptor puts the operator's hand in the primary beam on every exposure, defeating distance and shielding entirely.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Never hand-hold the tube head or hold the film/sensor in a patient's mouth",
          "why": "Hand-holding the tube or the image receptor puts the operator's hand in the primary beam on every exposure, defeating distance and shielding entirely."
        },
        {
          "detail": "Is a thyroid collar indicated for this exposure?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "standard-shield",
              "label": "Use apron with thyroid collar per current guidance for the exposure type and patient"
            },
            {
              "goto": "s5",
              "id": "collar-omit",
              "label": "Omit thyroid collar because it would obscure the diagnostic field (e.g., some panoramic/CBCT views)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Is a thyroid collar indicated for this exposure?"
        },
        {
          "detail": "Place the apron (and collar when used) on the patient, confirm no metal or jewelry is in the field, take the exposure, and note the shielding used and any collar-omission reason in the imaging log alongside the image.\n\nWhy: Recording collar-omission reasons protects both the patient and the practice's ALARA record if ever reviewed.\n\nRecord: shielding used, thyroid collar use or omission reason, exposure type, date, operator",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Apply shielding and document the exposure",
          "why": "Recording collar-omission reasons protects both the patient and the practice's ALARA record if ever reviewed."
        },
        {
          "detail": "Exposure shielding and documentation complete",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Exposure shielding and documentation complete"
        },
        {
          "detail": "Once a year the compliance officer reviews: current ALARA distance/barrier requirements, apron and collar inventory condition, posted diagrams still match room layout, and any FDA/ADA guidance updates since the last review.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual safety-policy review checklist"
        },
        {
          "detail": "The compliance officer signs and dates the annual policy review before it is re-posted; unresolved gaps (e.g., worn barrier, missing collar) are escalated to the practice owner for correction before sign-off.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer signs off on the reviewed policy.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer signs off on the reviewed policy"
        },
        {
          "detail": "The signed annual safety-policy review is filed with the practice's radiation safety program records and the next review date is calendared.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the signed annual review"
        },
        {
          "detail": "Operator positioning and shielding policy current",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Operator positioning and shielding policy current"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Radiation safety — operator position, distance, patient shielding policy — Every exposure; the annual safety review.",
      "title": "Radiation safety — operator position, distance, patient shielding policy",
      "trigger": "Every exposure; the annual safety review",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "open_standard",
          "label": "Radiographic interpretation, documentation and incidental-finding follow-up — generic functional equivalent (standard-of-care documentation practice)",
          "repaired": {
            "action": "generic",
            "evidence": "The only ADA 2023 text I could confirm by quote ('patients no longer be draped in abdominal lead aprons...') is about radiation-dose/shielding practice, not interpretation or incidental-finding follow-up. Follow-on search surfaced general professional-responsibility statements (e.g. 'the dentist who orders or uses CBCT is responsible for interpreting it... including findings outside the primary area of interest') from secondary commentary (JADA/Decisions in Dentistry), not a single citable primary ADA standard with a quotable passage on record-keeping for incidental findings.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA 2023 radiation protection recommendations (open)",
              "url": null
            }
          },
          "source": "No single located ADA/AAOMR publication was confirmed by direct quote to cover interpretation-documentation/incidental-finding-follow-up procedure specifically; treat as ordering-dentist standard-of-care documentation practice — generic functional equivalent"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2 (in-repo radiology basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2 (in-repo radiology basis)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "rad-010",
      "kind": "clinical",
      "materials": [
        "diagnostic-quality images on a calibrated monitor",
        "prior images for comparison when available",
        "structured interpretation template in the chart",
        "referral form/letter template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The dentist views each new image at full resolution on a calibrated monitor, comparing to prior images of the same area when available, before the patient is dismissed.\n\nWhy: Reviewing before dismissal catches technique failures that need a retake and lets same-visit findings be discussed with the patient.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review every image at diagnostic quality before the patient leaves",
          "why": "Reviewing before dismissal catches technique failures that need a retake and lets same-visit findings be discussed with the patient."
        },
        {
          "detail": "Was any AI-assisted image analysis tool used to flag findings?",
          "forks": [
            {
              "goto": "s10",
              "id": "ai-used",
              "label": "AI-assist tool flagged candidate findings for the dentist to review"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "no-ai",
              "label": "Manual interpretation only, no AI-assist tool used"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Was any AI-assisted image analysis tool used to flag findings?"
        },
        {
          "detail": "For each image series, the dentist documents normal findings, pathology, restorations present, bone levels, and any anatomical variants using the structured chart template, and dates and initials the entry.\n\nWhy: A structured, dated, initialed interpretation is the legal record that the images were actually read, not just filed.\n\nRecord: interpretation note per image series: normal/abnormal findings, date, dentist initials",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Chart the interpretation using the structured template",
          "why": "A structured, dated, initialed interpretation is the legal record that the images were actually read, not just filed."
        },
        {
          "detail": "Is there an incidental finding outside the original reason for the images?",
          "forks": [
            {
              "goto": "s8",
              "id": "no-incidental",
              "label": "No incidental finding"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "incidental-found",
              "label": "Incidental finding present (e.g., unexpected radiolucency, calcification, airway or sinus finding)"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is there an incidental finding outside the original reason for the images?"
        },
        {
          "detail": "The finding is described in plain clinical language, its location marked or noted, and a follow-up plan (watch, additional imaging, specialist referral) is recorded.\n\nRecord: incidental finding description, location, follow-up plan",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Flag and describe the incidental finding in the chart"
        },
        {
          "detail": "Does the finding warrant a specialist referral?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "refer",
              "label": "Refer to a specialist (e.g., oral surgeon, radiologist, physician) for evaluation"
            },
            {
              "goto": "s8",
              "id": "internal-watch",
              "label": "Monitor internally at next recall, no referral needed yet"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the finding warrant a specialist referral?"
        },
        {
          "detail": "The referral coordinator sends the relevant images and the dentist's written interpretation to the receiving specialist, and the patient is informed of the referral and its urgency.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Send referral with images and interpretation to the specialist"
        },
        {
          "detail": "The chart notes that the patient was informed of the finding (or that none was present) and any information given about next steps, in plain language framed as information to confirm with the dentist, not a diagnosis to act on alone.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm patient was notified of any finding"
        },
        {
          "detail": "Interpretation charted and any incidental finding tracked",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Interpretation charted and any incidental finding tracked"
        },
        {
          "detail": "Any AI-generated finding shown to the patient carries the AB 3030 disclosure 'AI-generated — reviewed by a licensed provider,' and the dentist independently confirms or rejects each flagged finding before it is charted or discussed.\n\nWhy: AB 3030 requires a provider-reviewed disclosure on GenAI-generated content that reaches a patient; an unreviewed AI flag is never presented as a diagnosis.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Disclose and review every AI-flagged finding before it is used",
          "why": "AB 3030 requires a provider-reviewed disclosure on GenAI-generated content that reaches a patient; an unreviewed AI flag is never presented as a diagnosis."
        },
        {
          "detail": "The dentist reviews and either confirms or rejects each AI-flagged candidate finding, signing off before any AI-generated finding is charted or discussed with the patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on each AI-flagged finding before it is charted or disclosed.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on each AI-flagged finding before it is charted or disclosed"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Radiographic interpretation, documentation and incidental-finding follow-up — Images are acquired; the interpretation must be charted, including unexpected findings.",
      "title": "Radiographic interpretation, documentation and incidental-finding follow-up",
      "trigger": "Images are acquired; the interpretation must be charted, including unexpected findings",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (2003) and Summary of Infection Prevention Practices (2016)",
          "url": "https://www.cdc.gov/dental-infection-control/hcp/summary/index.html"
        },
        {
          "kind": "regulation",
          "label": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "source": "California Dental Board Minimum Standards for Infection Control 16 CCR §1005",
          "url": "https://www.dbc.ca.gov/formspubs/regs_infection_control.shtml"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 3,
      "frequency": "per-use",
      "id": "rad-011",
      "kind": "clinical",
      "materials": [
        "single-use disposable sensor or plate barrier sleeves",
        "EPA-registered intermediate-level disinfectant wipes",
        "digital sensor or phosphor storage plate",
        "gloves",
        "designated clean/dirty zone at the imaging workstation"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Before touching a patient, the operator places a new single-use disposable barrier sleeve over the digital sensor or phosphor storage plate and its cable, checking the sleeve is intact with no tears.\n\nWhy: Intraoral sensors and plates contact mucosa and saliva directly and cannot themselves be sterilized between patients, so an intact barrier is the primary infection-control layer.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Sheathe the sensor or plate in a fresh barrier before each patient",
          "why": "Intraoral sensors and plates contact mucosa and saliva directly and cannot themselves be sterilized between patients, so an intact barrier is the primary infection-control layer."
        },
        {
          "detail": "The operator wears gloves throughout, avoids touching non-barrier surfaces (light switches, keyboard) with contaminated gloves, and completes the exposure series.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Expose images using standard aseptic technique"
        },
        {
          "detail": "Did the barrier sleeve tear or become visibly contaminated during use?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "barrier-intact",
              "label": "Barrier intact, no visible contamination"
            },
            {
              "goto": "s7",
              "id": "barrier-breach",
              "label": "Barrier torn or contamination reached the sensor/plate surface"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Did the barrier sleeve tear or become visibly contaminated during use?"
        },
        {
          "detail": "After the exposure, gloved hands remove and discard the barrier sleeve at the designated dirty zone, then place the now-unwrapped sensor or plate in the clean zone without touching other clean-zone surfaces.\n\nWhy: A clean/dirty zone split at the workstation prevents cross-contaminating the keyboard, imaging software controls, or the next patient's supplies.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Remove the barrier in the dirty zone and place the device in the clean zone",
          "why": "A clean/dirty zone split at the workstation prevents cross-contaminating the keyboard, imaging software controls, or the next patient's supplies."
        },
        {
          "detail": "Once ungloved and the barrier discarded, the operator wipes the sensor or plate body and cable with an EPA-registered intermediate-level disinfectant wipe for the full manufacturer contact time before it is stored or reused.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Wipe the sensor or plate with intermediate-level disinfectant"
        },
        {
          "detail": "Sensor/plate barrier and disinfection cycle complete",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Sensor/plate barrier and disinfection cycle complete"
        },
        {
          "detail": "If a breach occurred, the sensor or plate is removed from service, disinfected with an EPA-registered intermediate-level disinfectant per the product's contact time, and the breach is logged before the device returns to use.\n\nWhy: A torn barrier means the device itself, not just the sleeve, was exposed to oral fluids — the routine end-of-use wipe alone is not sufficient.\n\nRecord: barrier breach date, device, corrective action",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Treat a barrier breach as direct contamination",
          "why": "A torn barrier means the device itself, not just the sleeve, was exposed to oral fluids — the routine end-of-use wipe alone is not sufficient."
        },
        {
          "detail": "The compliance officer reviews the breach log and disinfection record and signs off before the sensor or plate is returned to clinical use.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms the device is safe to return to service.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms the device is safe to return to service"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Sensor and phosphor plate barriers, disinfection and handling — Every intraoral exposure.",
      "title": "Sensor and phosphor plate barriers, disinfection and handling",
      "trigger": "Every intraoral exposure",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "regulation",
          "label": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33",
          "source": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33",
          "url": "https://www.ecfr.gov/current/title-21/part-1020"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "rad-012",
      "kind": "clinical",
      "materials": [
        "state radiation control program registration form",
        "equipment make/model/serial number and installation date",
        "prior registration certificate (if renewing)",
        "renewal fee payment method",
        "floor plan showing unit location"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What triggered this filing?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-unit",
              "label": "New or relocated unit installed"
            },
            {
              "goto": "s6",
              "id": "disposed-unit",
              "label": "Unit sold, transferred or taken permanently out of service"
            },
            {
              "goto": "s7",
              "id": "renewal-notice",
              "label": "Routine state renewal notice arrived"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "What triggered this filing?"
        },
        {
          "detail": "Record the make, model, serial number, installation date, room location on the floor plan, and installing vendor for the new or relocated unit.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Gather the new unit's identifying information"
        },
        {
          "detail": "Submit the state radiation control program's registration form for the new or relocated unit, including the updated floor plan, within the state's required filing window from installation.\n\nWhy: Operating an unregistered x-ray unit is a regulatory violation independent of the unit's actual safety — the paperwork has its own deadline.\n\nRecord: registration filing date, unit serial number, confirmation number",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "File the registration with the state radiation control program",
          "why": "Operating an unregistered x-ray unit is a regulatory violation independent of the unit's actual safety — the paperwork has its own deadline."
        },
        {
          "detail": "The office manager updates the practice's equipment roster with the current registration status and calendars the next renewal or filing deadline.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the equipment roster and compliance calendar"
        },
        {
          "detail": "Equipment registration current",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Equipment registration current"
        },
        {
          "detail": "Submit the state's disposal/transfer notification for the unit being sold, transferred, or permanently retired, including the new owner's information if transferred.\n\nRecord: disposal/transfer date, unit serial number, receiving party if transferred",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "File the disposal or transfer notice"
        },
        {
          "detail": "Compare the renewal notice against the current equipment roster to confirm no units have changed, then prepare the renewal fee payment.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the renewal notice details and confirm no equipment changes"
        },
        {
          "detail": "The practice owner or authorized signer approves the renewal fee payment before it is submitted.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner approves the renewal fee payment.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner approves the renewal fee payment"
        },
        {
          "detail": "Pay the renewal fee through the state's designated channel and file the resulting updated registration certificate with the practice's radiation safety program records.\n\nRecord: renewal payment date, confirmation number, new expiration date",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the renewal payment and file the new certificate"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Registering new, moved or disposed x-ray or CBCT equipment with the state and paying the renewal fee — A unit is installed, relocated, sold or taken out of service, or the state renewal notice arrives.",
      "title": "Registering new, moved or disposed x-ray or CBCT equipment with the state and paying the renewal fee",
      "trigger": "A unit is installed, relocated, sold or taken out of service, or the state renewal notice arrives",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2 (in-repo radiology basis)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2 (in-repo radiology basis)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "rad-013",
      "kind": "clinical",
      "materials": [
        "current equipment registration certificates",
        "operator certification records",
        "shielding survey and dosimetry reports",
        "written radiation safety program document",
        "inspection findings report / notice of violation",
        "corrective action tracking sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "On notice of a scheduled inspection (or upon an unannounced inspector arrival), the compliance officer assembles current equipment registration certificates, operator certification records, shielding survey reports, dosimetry reports, and the written radiation safety program.\n\nWhy: Most inspection findings are documentation gaps, not physical hazards — having the packet ready is the single biggest lever on outcome.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the inspection scope and prepare the document packet",
          "why": "Most inspection findings are documentation gaps, not physical hazards — having the packet ready is the single biggest lever on outcome."
        },
        {
          "detail": "The compliance officer (or dentist if the compliance officer is unavailable) accompanies the inspector throughout the visit, answers questions directly, and does not let other staff independently answer regulatory questions.\n\nWhy: A single, prepared point of contact avoids inconsistent answers from staff who don't know the full compliance picture.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Designate a single point of contact for the inspector",
          "why": "A single, prepared point of contact avoids inconsistent answers from staff who don't know the full compliance picture."
        },
        {
          "detail": "Note which records the inspector reviewed, which rooms/equipment were checked, and any verbal concerns raised, even before a written report arrives.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document everything the inspector reviews and any verbal findings"
        },
        {
          "detail": "Did the inspection identify any deficiency or a notice of violation?",
          "forks": [
            {
              "goto": "s9",
              "id": "clean",
              "label": "No deficiencies identified"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "deficiency-found",
              "label": "Deficiency or notice of violation issued"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did the inspection identify any deficiency or a notice of violation?"
        },
        {
          "detail": "Each deficiency from the written findings or notice of violation is logged with the specific requirement cited, the corrective action needed, an assigned owner, and the state's deadline.\n\nRecord: deficiency description, citation, owner, deadline",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log each deficiency with its required correction deadline"
        },
        {
          "detail": "The assigned owner (office manager for equipment/paperwork items, dentist for clinical-practice items) completes each corrective action — e.g., retraining, equipment repair, updated shielding, corrected registration — and documents the completion.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete each corrective action"
        },
        {
          "detail": "The compliance officer independently verifies each corrective action was actually completed (not just marked complete) before signing off, and the dentist co-signs any deficiency tied to clinical practice.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer verifies and signs off each corrective action.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer verifies and signs off each corrective action"
        },
        {
          "detail": "The compliance officer submits documented proof of each corrective action to the state radiation control program before the stated deadline, and retains a copy.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Submit proof of correction to the state within the deadline"
        },
        {
          "detail": "The full inspection record — packet reviewed, findings, corrective actions, proof of correction — is filed with the radiation safety program records, and any recurring next-inspection date is calendared.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the inspection outcome and update the compliance calendar"
        },
        {
          "detail": "Inspection closed out, deficiencies corrected and documented",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Inspection closed out, deficiencies corrected and documented"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "State radiation inspector visit and deficiency correction — The state schedules or performs an inspection, or a notice of violation arrives.",
      "title": "State radiation inspector visit and deficiency correction",
      "trigger": "The state schedules or performs an inspection, or a notice of violation arrives",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California B&P §1656 auxiliary radiation safety certification requirement",
          "source": "California B&P §1656 auxiliary radiation safety certification requirement",
          "url": "https://www.dbc.ca.gov/applicants/course_rs.pdf"
        },
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "once",
      "id": "rad-014",
      "kind": "clinical",
      "materials": [
        "state auxiliary radiation safety certificate or license",
        "personnel file",
        "certification tracking spreadsheet or system",
        "renewal reminder calendar"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "assistant",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Before a new assistant or hygienist is scheduled to expose any radiographic image, the office manager requests a copy of their state auxiliary radiation safety certificate (or equivalent license authorizing radiographic exposure).\n\nWhy: Only certified personnel may legally expose dental radiographs in most states — this has to be confirmed before, not after, the first exposure.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Request the certificate before the first exposure",
          "why": "Only certified personnel may legally expose dental radiographs in most states — this has to be confirmed before, not after, the first exposure."
        },
        {
          "detail": "The office manager cross-checks the certificate number, name, and expiration date against the state dental board's public license verification tool.\n\nWhy: A photocopy alone can be outdated or altered; the state lookup confirms current, active status.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify the certificate against the state's public license lookup",
          "why": "A photocopy alone can be outdated or altered; the state lookup confirms current, active status."
        },
        {
          "detail": "Is the certification current and active?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "current",
              "label": "Certification verified current and active"
            },
            {
              "goto": "s8",
              "id": "expired-or-missing",
              "label": "Certification expired, not found, or pending"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the certification current and active?"
        },
        {
          "detail": "A copy of the verified certificate, the verification date, and the license expiration date are filed in the employee's personnel file and logged in the certification tracking system.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "File the verified certificate in the personnel file"
        },
        {
          "detail": "A reminder is calendared ahead of the certificate's expiration date so renewal can be tracked before it lapses.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Set a renewal reminder before the expiration date"
        },
        {
          "detail": "The office manager confirms to the dentist and the staff member that certification is verified and the staff member is cleared to take radiographs.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Clear the staff member to expose radiographs"
        },
        {
          "detail": "Operator certification verified and on file",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Operator certification verified and on file"
        },
        {
          "detail": "If certification cannot be verified as current, the dentist directs that the staff member does not expose any radiographs until a valid, current certificate is produced and verified.\n\nWhy: Allowing an uncertified person to expose radiographs is both a regulatory violation and outside the practice's malpractice coverage.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist blocks radiograph exposure until certification is confirmed.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist blocks radiograph exposure until certification is confirmed",
          "why": "Allowing an uncertified person to expose radiographs is both a regulatory violation and outside the practice's malpractice coverage."
        },
        {
          "detail": "The office manager follows up with the staff member on the certification status and re-runs the verification once a current certificate is available, looping back to the verification step.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Follow up until a valid certificate is on file"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Verifying radiation safety certification for every person who exposes films — A new assistant or hygienist is asked to take radiographs.",
      "title": "Verifying radiation safety certification for every person who exposes films",
      "trigger": "A new assistant or hygienist is asked to take radiographs",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "source": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "url": "https://ncrponline.org/publications/reports/ncrp-report-177/"
        },
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "regulation",
          "label": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33",
          "source": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33",
          "url": "https://www.ecfr.gov/current/title-21/part-1020"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "rad-015",
      "kind": "clinical",
      "materials": [
        "qualified expert / medical physicist contract",
        "room floor plan with wall construction and shielding materials",
        "survey report template",
        "prior survey report (if re-survey)",
        "equipment inventory list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What triggered the need for a survey?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-construction",
              "label": "New unit installed or room newly built/renovated"
            },
            {
              "goto": "s2",
              "id": "layout-change",
              "label": "Adjacent room use or wall layout changed"
            },
            {
              "goto": "s10",
              "id": "interval-elapsed",
              "label": "Routine periodic survey interval has elapsed"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What triggered the need for a survey?"
        },
        {
          "detail": "For a new or renovated room, the compliance officer schedules the qualified expert survey before the unit is used on any patient, and holds clinical use of that room until the survey clears.\n\nWhy: Shielding adequacy has to be confirmed before patients or staff in adjacent spaces are exposed to the new source, not after.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the survey before the room is placed in clinical use",
          "why": "Shielding adequacy has to be confirmed before patients or staff in adjacent spaces are exposed to the new source, not after."
        },
        {
          "detail": "A qualified expert (medical physicist or equivalent per state definition) measures shielding adequacy at the walls, floor and ceiling of the x-ray room, and checks the unit's output, collimation, filtration and timer accuracy against the FDA performance standard.\n\nWhy: This measurement can only be done by a qualified expert with calibrated survey instruments — it is not a self-check.",
          "id": "s3",
          "kind": "step",
          "role": "it-vendor",
          "title": "Qualified expert performs the shielding evaluation and equipment survey",
          "why": "This measurement can only be done by a qualified expert with calibrated survey instruments — it is not a self-check."
        },
        {
          "detail": "Did the survey identify any deficiency?",
          "forks": [
            {
              "goto": "s7",
              "id": "passed",
              "label": "Survey passed with no deficiencies"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "deficiency",
              "label": "Shielding or equipment deficiency identified"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did the survey identify any deficiency?"
        },
        {
          "detail": "The identified deficiency (e.g., additional lead lining, unit recalibration, output adjustment) is corrected by a qualified vendor before the room resumes clinical use.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Correct the deficiency before returning the room to use"
        },
        {
          "detail": "The qualified expert re-measures the corrected item to confirm it now meets the acceptance criteria before the room is cleared.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Re-survey to confirm the correction"
        },
        {
          "detail": "The practice owner reviews the passing survey report and signs off before the room (or newly installed unit) is used clinically.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner signs off before the room returns to clinical use.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner signs off before the room returns to clinical use"
        },
        {
          "detail": "The signed survey report is filed with the radiation safety program records, and the next periodic survey date is calendared.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the survey report and calendar the next interval"
        },
        {
          "detail": "Shielding and equipment survey current, room cleared for use",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Shielding and equipment survey current, room cleared for use"
        },
        {
          "detail": "The compliance officer schedules the qualified expert to perform the periodic re-survey per the state-required interval, pulling the prior survey report for comparison.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the periodic re-survey"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Shielding evaluation and periodic equipment survey by a qualified expert — A new unit or room is built, the wall layout changes, or the survey interval elapses.",
      "title": "Shielding evaluation and periodic equipment survey by a qualified expert",
      "trigger": "A new unit or room is built, the wall layout changes, or the survey interval elapses",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "source": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "url": "https://ncrponline.org/publications/reports/ncrp-report-177/"
        },
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "quarterly",
      "id": "rad-016",
      "kind": "clinical",
      "materials": [
        "personnel dosimetry badges (one per operator plus a control badge)",
        "badge exchange mailer/return kit",
        "dose report from the dosimetry vendor",
        "investigation level threshold documentation",
        "personnel dose log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "office-manager",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "What triggered this cycle?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-operator",
              "label": "New operator is starting and needs a badge issued"
            },
            {
              "goto": "s5",
              "id": "exchange-cycle",
              "label": "Routine badge exchange cycle has arrived"
            },
            {
              "goto": "s8",
              "id": "elevated-reading",
              "label": "A dose report shows a reading at or above the investigation level"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "What triggered this cycle?"
        },
        {
          "detail": "The compliance officer assigns a personal dosimetry badge to the new operator before they take any exposures, labeled with their name and start date, and logs the issue date.\n\nWhy: Every person who exposes radiographs needs individual dose tracking from their first exposure, not retroactively.\n\nRecord: badge issue date, operator name",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Issue a badge to the new operator",
          "why": "Every person who exposes radiographs needs individual dose tracking from their first exposure, not retroactively."
        },
        {
          "detail": "The operator is instructed to wear the badge at collar level during all radiographic exposures and to store it away from the x-ray unit when not in use, never wearing it under a lead apron.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Instruct the operator on badge wear"
        },
        {
          "detail": "Dosimetry program current, any elevated reading investigated and closed",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Dosimetry program current, any elevated reading investigated and closed"
        },
        {
          "detail": "At the exchange cycle date, the compliance officer collects all worn badges (including the control badge) and ships them to the dosimetry vendor, immediately issuing replacement badges so no operator goes without one.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Mail the worn badges for reading and issue replacements"
        },
        {
          "detail": "Wait for the dosimetry vendor to process the exchanged badges and return the dose report, typically within the vendor's standard turnaround window.",
          "id": "s6",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 1209600,
          "title": "Wait for the vendor's dose report"
        },
        {
          "detail": "Does the dose report show any reading at or above the investigation level?",
          "forks": [
            {
              "goto": "s10",
              "id": "all-normal",
              "label": "All readings within normal range"
            },
            {
              "advised": true,
              "goto": "s8",
              "id": "elevated",
              "label": "One or more readings at or above the investigation level"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the dose report show any reading at or above the investigation level?"
        },
        {
          "detail": "The compliance officer opens an investigation: interview the operator about their exposure pattern for the period, check whether the badge was worn correctly and consistently, and check equipment and shielding logs for the same period.\n\nWhy: An elevated reading can come from actual overexposure, incorrect badge wear, or badge damage/exposure to a non-occupational source — the cause has to be established, not assumed.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Open an investigation for the elevated reading",
          "why": "An elevated reading can come from actual overexposure, incorrect badge wear, or badge damage/exposure to a non-occupational source — the cause has to be established, not assumed."
        },
        {
          "detail": "The compliance officer and dentist jointly review the investigation findings and any corrective action (retraining on badge wear, equipment check, workflow change) before signing off that the operator may resume routine radiographic duties.\n\nWhy: A licensed-scope sign-off before resuming duties ensures a genuine overexposure isn't waved through as a badge-wear error.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer and dentist review the investigation before the operator resumes routine exposures.",
            "role": "dentist and compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer and dentist review the investigation before the operator resumes routine exposures",
          "why": "A licensed-scope sign-off before resuming duties ensures a genuine overexposure isn't waved through as a badge-wear error."
        },
        {
          "detail": "The dose report (and investigation record, if one was opened) is filed in the personnel dose log, retained per the state's required retention period.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the dose report and any investigation record"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Personnel dosimetry badge issue, exchange, dose-report review and elevated-reading investigation — A new operator starts, the badge exchange cycle arrives, or a dose report exceeds the investigation level.",
      "title": "Personnel dosimetry badge issue, exchange, dose-report review and elevated-reading investigation",
      "trigger": "A new operator starts, the badge exchange cycle arrives, or a dose report exceeds the investigation level",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq.",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "open_standard",
          "label": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard) — occupational dose limits and voluntary declared-pregnant-worker provisions",
          "source": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard) — occupational dose limits and voluntary declared-pregnant-worker provisions",
          "url": "https://ncrponline.org/publications/reports/ncrp-report-177/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics — dosimetry badge use)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics — dosimetry badge use)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rad-017",
      "kind": "clinical",
      "materials": [
        "written declaration-of-pregnancy form",
        "second dosimetry badge (fetal/waist badge)",
        "occupational dose history log",
        "state radiation control program contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hr",
        "compliance-officer",
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The declaration is voluntary and confidential under state radiation-control rules; it is made in writing to HR or the office manager and dated. Nothing is assumed or acted on from a verbal mention alone.\n\nWhy: A written, dated declaration is what starts the fetal-dose-limit clock and protects the employee's choice not to declare.",
          "id": "s1",
          "kind": "step",
          "role": "hr",
          "title": "Team member submits a voluntary written pregnancy declaration",
          "why": "A written, dated declaration is what starts the fetal-dose-limit clock and protects the employee's choice not to declare."
        },
        {
          "detail": "HR hands the dated declaration to the compliance officer (the person who owns the radiation safety program) same-day, without discussing it with other staff.\n\nRecord: Declaration date and routing logged in the personnel radiation-safety file, access-restricted.",
          "id": "s2",
          "kind": "step",
          "role": "hr",
          "title": "Route the declaration to the compliance officer"
        },
        {
          "detail": "Before pulling any personal dose history, confirm with the employee that she wants the review to proceed and understands it is confidential and voluntary.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the employee consents to the fetal-dose review proceeding.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm the employee consents to the fetal-dose review proceeding"
        },
        {
          "detail": "Retrieve the current-year dosimetry badge readings and compute cumulative occupational dose to date so the fetal dose limit can be tracked against it going forward.\n\nWhy: The fetal dose limit applies for the remainder of the pregnancy, so the starting point has to be known.\n\nRecord: Dose history summary filed with the declaration.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the employee's occupational dose history for the year to date",
          "why": "The fetal dose limit applies for the remainder of the pregnancy, so the starting point has to be known."
        },
        {
          "detail": "A second badge worn at waist level under any lead apron gives a closer estimate of fetal dose than the collar badge alone; label it clearly and add it to the badge exchange schedule.\n\nWhy: The collar badge overestimates dose to the abdomen when an apron is worn, so a waist badge is the more accurate fetal-dose proxy.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "fetal/waist dosimetry badge"
          ],
          "role": "compliance-officer",
          "title": "Issue a second, waist-level dosimetry badge",
          "why": "The collar badge overestimates dose to the abdomen when an apron is worn, so a waist badge is the more accurate fetal-dose proxy."
        },
        {
          "detail": "Review the employee's typical radiographic workload against the fetal dose limit and current exposure trend.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "continue",
              "label": "Continue current duties with waist badge monitoring"
            },
            {
              "goto": "s11",
              "id": "reassign",
              "label": "Temporarily reassign away from primary radiograph duties"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether current duties need adjustment"
        },
        {
          "detail": "Review the waist-badge reading against the cumulative fetal dose limit every badge-exchange cycle (monthly) for the remainder of the declared pregnancy.",
          "id": "s7",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 2592000,
          "title": "Monitor monthly badge readings through the declared pregnancy"
        },
        {
          "detail": "Is any monthly reading elevated relative to the fetal limit trend?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "normal",
              "label": "Readings track normally"
            },
            {
              "goto": "s12",
              "id": "elevated",
              "label": "A reading is elevated"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is any monthly reading elevated relative to the fetal limit trend?"
        },
        {
          "detail": "Document final cumulative dose, retire the waist badge, and note whether the employee withdrew the declaration at any point (her right, at any time).\n\nRecord: Personnel radiation-safety file: full dose trend for the declared period.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close out the review at end of declared pregnancy or on withdrawal"
        },
        {
          "detail": "Pregnancy dose-protection review closed",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pregnancy dose-protection review closed"
        },
        {
          "detail": "Shift the employee's schedule so another certified operator covers radiograph exposures for the declared period; document the change without disclosing the reason to unrelated staff.\n\nWhy: Reassignment is the employee's option, not a requirement, and stays confidential.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange temporary duty reassignment",
          "why": "Reassignment is the employee's option, not a requirement, and stays confidential."
        },
        {
          "detail": "Follow the practice's elevated-dose investigation procedure (see rad-016) — confirm the badge was worn correctly, check equipment, and involve the dentist and the employee in reviewing next steps.\n\nWhy: An elevated reading during a declared pregnancy needs faster, more conservative follow-up than routine badge review.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Open an elevated-reading investigation",
          "why": "An elevated reading during a declared pregnancy needs faster, more conservative follow-up than routine badge review."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Staff pregnancy declaration and fetal-dose protection review — A team member who exposes radiographs declares a pregnancy.",
      "title": "Staff pregnancy declaration and fetal-dose protection review",
      "trigger": "A team member who exposes radiographs declares a pregnancy",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "regulation",
          "label": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33",
          "source": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33",
          "url": "https://www.ecfr.gov/current/title-21/part-1020"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.3 (in-repo periapical technique — common retake causes)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.3 (in-repo periapical technique — common retake causes)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "monthly",
      "id": "rad-018",
      "kind": "clinical",
      "materials": [
        "retake log (paper or PMS module)",
        "image quality checklist",
        "manufacturer calibration reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Immediately after a retake, record the unit used, tooth/view, and the reason (patient movement, positioning, cone-cut, elongation/foreshortening, sensor placement, exposure setting, processing error) in the retake log.\n\nWhy: Logging at the moment of the retake, rather than from memory later, keeps the reason accurate and the count complete.\n\nRecord: Retake log: date, unit, view, reason.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Log every retake at the time it happens",
          "why": "Logging at the moment of the retake, rather than from memory later, keeps the reason accurate and the count complete."
        },
        {
          "detail": "The retake log accumulates through the month; the compliance officer reviews it on the same calendar date each month.",
          "id": "s2",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 2592000,
          "title": "Wait for the monthly QA review date"
        },
        {
          "detail": "Divide retakes by total exposures for the month to get a retake-rate percentage, and rank reasons by frequency.\n\nWhy: A rate, not a raw count, is what is comparable month to month as patient volume changes.\n\nRecord: Monthly QA summary with retake rate and top reasons.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Tally the month's retakes and compute the retake rate",
          "why": "A rate, not a raw count, is what is comparable month to month as patient volume changes."
        },
        {
          "detail": "Check: contrast/density acceptable, no visible artifact or dust on sensor, correct collimation with no cone-cut, positioning error rate, processing/software error rate.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Run the image quality checklist against a sample of recent images"
        },
        {
          "detail": "Is the retake rate or a specific cause trending above the practice's threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "within-range",
              "label": "Retake rate and causes within normal range"
            },
            {
              "goto": "s8",
              "id": "above-threshold",
              "label": "Retake rate or one cause is trending high"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the retake rate or a specific cause trending above the practice's threshold?"
        },
        {
          "detail": "The monthly summary, findings, and any corrective action taken are signed and filed in the radiation safety program record.\n\nRecord: Monthly QA summary, signed, filed.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Sign and file the monthly QA summary"
        },
        {
          "detail": "Monthly retake and QA review closed",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Monthly retake and QA review closed"
        },
        {
          "detail": "Identify whether the cause is technique, equipment, or both",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "technique",
              "label": "Technique-related (positioning, patient management)"
            },
            {
              "goto": "s10",
              "id": "equipment",
              "label": "Equipment-related (sensor, unit output, processing)"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Identify whether the cause is technique, equipment, or both"
        },
        {
          "detail": "A short hands-on refresher on paralleling technique or sensor placement, referencing rad-002/rad-003, targeted at the specific error pattern seen in the log.\n\nWhy: Correcting the specific pattern (e.g. repeated cone-cut) is faster than a generic retraining and is what the data pointed to.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Schedule a brief technique refresher for the operator(s) involved",
          "why": "Correcting the specific pattern (e.g. repeated cone-cut) is faster than a generic retraining and is what the data pointed to."
        },
        {
          "detail": "Compare current output/exposure settings and sensor condition to the manufacturer's calibration reference; if out of tolerance, escalate for a qualified expert survey (see rad-015) or service call.\n\nWhy: Equipment drift causes clustered retakes across multiple operators, which technique retraining alone would not fix.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check equipment against manufacturer calibration reference",
          "why": "Equipment drift causes clustered retakes across multiple operators, which technique retraining alone would not fix."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Retake log, image quality assurance review and equipment calibration — A radiograph is retaken, the monthly QA review is due, or image quality drifts.",
      "title": "Retake log, image quality assurance review and equipment calibration",
      "trigger": "A radiograph is retaken, the monthly QA review is due, or image quality drifts",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq. — protective apparel inspection requirements",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq. — protective apparel inspection requirements",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "open_standard",
          "label": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "source": "NCRP Report No. 177 Radiation Protection in Dentistry (referenced standard)",
          "url": "https://ncrponline.org/publications/reports/ncrp-report-177/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics — apron/collar use for all patients)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics — apron/collar use for all patients)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "annual",
      "id": "rad-019",
      "kind": "clinical",
      "materials": [
        "lead aprons and thyroid collars (all units)",
        "fluoroscopic or radiographic inspection method (per state requirement) or a visual/manual flex check",
        "apron inspection log",
        "hanging storage rack"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Set a recurring annual calendar reminder; also treat any staff-reported crack, tear, or crease as an immediate out-of-cycle inspection trigger for that item.\n\nWhy: Lead shielding degrades from folding and handling over time, and visible creases can mean the lead layer has cracked even if the covering looks fine.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the annual inspection date, or trigger on visible damage",
          "why": "Lead shielding degrades from folding and handling over time, and visible creases can mean the lead layer has cracked even if the covering looks fine."
        },
        {
          "detail": "Collect all protective apparel from every operatory and any loaner or spare units — the inspection covers all of them, not a sample.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Gather every apron and thyroid collar in the practice"
        },
        {
          "detail": "For each apron/collar: check for visible cracks, tears, or excessive creasing in the covering; flex-check by hand along seams and fold lines feeling for lumps or gaps in the lead layer; where the practice uses a radiographic or fluoroscopic screening method per state requirement, image the item and check for shadowing/gaps indicating lead discontinuity.\n\nWhy: A crack or gap in the lead layer defeats the shielding purpose even when the item still looks and feels intact on the outside.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Inspect each item for integrity",
          "why": "A crack or gap in the lead layer defeats the shielding purpose even when the item still looks and feels intact on the outside."
        },
        {
          "detail": "Does the item pass inspection?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "pass",
              "label": "Passes — no defects found"
            },
            {
              "goto": "s7",
              "id": "fail",
              "label": "Fails — defect found"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the item pass inspection?"
        },
        {
          "detail": "Record item identifier (label each apron/collar with a permanent ID), inspection date, method used, and result.\n\nRecord: Apron inspection log entry: pass, date, method, inspector.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the passing item with date and inspector"
        },
        {
          "detail": "Are more items left to inspect?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "more",
              "label": "Yes, continue with the next apron/collar"
            },
            {
              "goto": "s8",
              "id": "done",
              "label": "No, all items inspected"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Are more items left to inspect?"
        },
        {
          "detail": "Tag the failed item clearly, remove it from the operatory rotation the same day, and replace it before the next patient use of that room requires shielding.\n\nWhy: A defective apron in circulation is worse than none, because staff and patients believe they are protected when they are not.\n\nRecord: Apron inspection log entry: fail, defect description, date retired, replacement ordered/installed.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Immediately remove the item from service",
          "why": "A defective apron in circulation is worse than none, because staff and patients believe they are protected when they are not."
        },
        {
          "detail": "Hang aprons and collars flat on a rack rather than folding them over a hook or chair back — folding is the leading cause of lead cracking between inspections.\n\nWhy: Correct storage between uses is what keeps the next annual inspection from finding the same failure pattern again.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Return all passing items to proper hanging storage",
          "why": "Correct storage between uses is what keeps the next annual inspection from finding the same failure pattern again."
        },
        {
          "detail": "Total items inspected, pass/fail count, and any items retired and replaced, filed in the radiation safety program record.\n\nRecord: Annual apron inspection summary.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the annual summary"
        },
        {
          "detail": "Annual apron and collar inspection closed",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual apron and collar inspection closed"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Lead apron and thyroid collar integrity inspection — The annual inspection date, or an apron shows cracks or creases.",
      "title": "Lead apron and thyroid collar integrity inspection",
      "trigger": "The annual inspection date, or an apron shows cracks or creases",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "21 CFR 1002.20 (FDA) — manufacturer and facility reporting of Accidental Radiation Occurrences (AROs), including patient overexposure or equipment malfunction",
          "repaired": {
            "action": "replace",
            "evidence": "21 CFR § 1002.20 - Reporting of accidental radiation occurrences. ... manufacturers of radiation-emitting electronic products [must], upon becoming aware, immediately report accidental radiation occurrences (AROs) to CDRH ... Reports must contain ... the nature of the accidental radiation occurrence ... the number of persons involved, adversely affected, or exposed ... and the nature and magnitude of their exposure.",
            "ticket": "PROT-017",
            "was": {
              "source": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33 — malfunction reporting",
              "url": "https://www.ecfr.gov/current/title-21/part-1020"
            }
          },
          "source": "21 CFR 1002.20",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-J/part-1002/subpart-C/section-1002.20"
        },
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq. — reportable radiation incidents",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq. — reportable radiation incidents",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "rad-020",
      "kind": "clinical",
      "materials": [
        "incident report form",
        "unit service/maintenance log",
        "state radiation control program contact",
        "manufacturer service line contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "compliance-officer",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The moment a fault is suspected — exposure that will not terminate, an exposure without the operator pressing the button, or any sign the patient received more radiation than intended — stop and do not use that unit again until cleared.\n\nWhy: Continuing to use a faulty unit risks repeating the overexposure on the next patient.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Stop using the unit immediately",
          "why": "Continuing to use a faulty unit risks repeating the overexposure on the next patient."
        },
        {
          "detail": "Report exactly what happened — which unit, what the display or behavior showed, and the patient involved — to the dentist before anyone else uses the room.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Notify the treating dentist immediately"
        },
        {
          "detail": "Physically tag the unit 'OUT OF SERVICE — DO NOT USE' and power it down or lock the operatory so no one uses it before a qualified expert or service technician inspects it.\n\nWhy: A tag alone can be ignored in a busy schedule; removing power or access prevents accidental reuse.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Tag the unit out of service and disconnect or lock it out",
          "why": "A tag alone can be ignored in a busy schedule; removing power or access prevents accidental reuse."
        },
        {
          "detail": "The dentist reviews what is known about the exposure (settings, duration if determinable, unit history) and determines the clinical significance before any patient communication is drafted.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews the patient's exposure and clinical significance before anything is communicated to the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews the patient's exposure and clinical significance before anything is communicated to the patient"
        },
        {
          "detail": "Use available unit output data and exposure parameters to estimate the dose; contact the manufacturer's service line or a qualified radiation expert if the estimate is not straightforward.\n\nWhy: An accurate estimate is necessary both for patient communication and for determining whether the incident is reportable to the state.\n\nRecord: Estimated dose, method used, and who performed the estimate.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Estimate the dose received, with help from the manufacturer or a qualified expert if needed",
          "why": "An accurate estimate is necessary both for patient communication and for determining whether the incident is reportable to the state."
        },
        {
          "detail": "Does the incident meet the state radiation control program's reporting threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "not-reportable",
              "label": "Below threshold — internal correction only"
            },
            {
              "goto": "s13",
              "id": "reportable",
              "label": "Meets or may meet the reporting threshold"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the incident meet the state radiation control program's reporting threshold?"
        },
        {
          "detail": "Full incident report filed even when not state-reportable, including cause, corrective action, and unit status.\n\nRecord: Internal incident report.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the incident internally"
        },
        {
          "detail": "The dentist, not front desk or assistant staff, explains to the patient what happened, the estimated dose in plain terms and context (e.g. comparison to routine background exposure where that helps understanding), and what is being done about the equipment.\n\nWhy: Direct disclosure by the licensed provider is both the right thing to do and reduces the risk of the incident being perceived as concealed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist discloses the incident to the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist discloses the incident to the patient",
          "why": "Direct disclosure by the licensed provider is both the right thing to do and reduces the risk of the incident being perceived as concealed."
        },
        {
          "detail": "Coordinate with the manufacturer's or an independent service technician to inspect, repair, and functionally test the unit before it returns to service.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand the unit to a service technician for inspection and repair"
        },
        {
          "detail": "Confirm the service technician's functional test results and, where required, a qualified expert re-survey, before removing the out-of-service tag.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify repair and re-test before returning the unit to use"
        },
        {
          "detail": "File final documentation: cause, corrective action, service records, patient disclosure note, and state notification if applicable.\n\nRecord: Closed incident file in the radiation safety program record.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close the incident record"
        },
        {
          "detail": "Overexposure/equipment-fault incident closed",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Overexposure/equipment-fault incident closed"
        },
        {
          "detail": "File the notification with the state radiation control program within the timeline the regulation requires, including the estimated dose, unit identification, and corrective action taken.\n\nWhy: Overexposure incidents above the state's threshold are a regulatory reporting obligation, not a discretionary courtesy.\n\nRecord: State notification copy filed with the incident record.",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the state radiation control program per the regulatory timeline",
          "why": "Overexposure incidents above the state's threshold are a regulatory reporting obligation, not a discretionary courtesy."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Suspected patient overexposure or x-ray equipment fault — A unit fails to terminate exposure, exposes without command, or a patient receives an unintended exposure.",
      "title": "Suspected patient overexposure or x-ray equipment fault",
      "trigger": "A unit fails to terminate exposure, exposes without command, or a patient receives an unintended exposure",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33 — handheld unit backscatter shield requirement",
          "source": "FDA performance standard for diagnostic x-ray systems 21 CFR 1020.30–1020.33 — handheld unit backscatter shield requirement",
          "url": "https://www.ecfr.gov/current/title-21/part-1020"
        },
        {
          "kind": "regulation",
          "label": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq. — handheld unit registration and operator distance/shielding rules",
          "source": "California Radiation Control Law H&S §114960 et seq. and 17 CCR §30100 et seq. — handheld unit registration and operator distance/shielding rules",
          "url": "https://www.cdph.ca.gov/Programs/CEH/DRSEM/Pages/RHB.aspx"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics — operator distance and shielding)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.2 (in-repo radiation safety basics — operator distance and shielding)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "rad-021",
      "kind": "clinical",
      "materials": [
        "handheld x-ray device with backscatter shield",
        "personal dosimetry badge",
        "locked storage cabinet",
        "operator certification record"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the operator certification record before anyone is allowed to use the handheld device — the certification and training for a fixed wall-mounted unit does not automatically cover handheld operation.\n\nWhy: Handheld technique (backscatter shield positioning, operator body position) differs enough from a fixed unit that separate competency confirmation matters.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify the operator holds current certification for handheld unit use",
          "why": "Handheld technique (backscatter shield positioning, operator body position) differs enough from a fixed unit that separate competency confirmation matters."
        },
        {
          "detail": "Check the shield is properly seated on the device, undamaged, and positioned between the tube head and the operator for every single exposure.\n\nWhy: The backscatter shield is what makes handheld operation safe at close range — a missing or damaged shield changes the entire safety profile of the device.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the backscatter shield is attached and intact before every use",
          "why": "The backscatter shield is what makes handheld operation safe at close range — a missing or damaged shield changes the entire safety profile of the device."
        },
        {
          "detail": "Stand behind the shield at the angle and distance specified in the device's operating instructions; never hold the unit with the shield turned away from the body.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Position the operator per the device's approved stance"
        },
        {
          "detail": "The handheld unit's frequent, closer-range use makes consistent badge wear especially important; confirm the badge is worn before exposure, not assumed.\n\nWhy: Handheld operators typically accumulate more exposures per shift at closer range than fixed-unit operators, so badge discipline matters more here.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the operator is wearing a personal dosimetry badge",
          "why": "Handheld operators typically accumulate more exposures per shift at closer range than fixed-unit operators, so badge discipline matters more here."
        },
        {
          "detail": "Follow the same positioning and technique standards as the equivalent fixed-unit view (see rad-002/rad-003), adapted for the handheld form factor.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Take the exposure per the prescribed view"
        },
        {
          "detail": "Is the device going back into storage now, or being used for another patient immediately?",
          "forks": [
            {
              "advised": true,
              "goto": "s1",
              "id": "next-patient",
              "label": "Used again immediately for another prescribed exposure"
            },
            {
              "goto": "s7",
              "id": "storage",
              "label": "Returning to storage"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the device going back into storage now, or being used for another patient immediately?"
        },
        {
          "detail": "Handheld units are portable and higher-theft-risk than fixed equipment; store in a locked cabinet accessible only to certified operators, not left on a mobile cart in an open area.\n\nWhy: A portable radiation-emitting device left accessible is both a security risk and a regulatory storage requirement in most states.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Return the device to locked storage",
          "why": "A portable radiation-emitting device left accessible is both a security risk and a regulatory storage requirement in most states."
        },
        {
          "detail": "Record which operator, how many exposures, and confirm badge and shield checks were completed, as part of the radiation safety program record.\n\nRecord: Handheld device usage log.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the day's handheld usage"
        },
        {
          "detail": "Handheld device use cycle closed",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Handheld device use cycle closed"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Handheld x-ray device operator controls and storage — A handheld unit is purchased or used outside a shielded operatory.",
      "title": "Handheld x-ray device operator controls and storage",
      "trigger": "A handheld unit is purchased or used outside a shielded operatory",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California AB 3030 (H&S §1339.75) — disclosure requirement on GenAI-generated patient-facing clinical communications unless provider-reviewed",
          "source": "California AB 3030 (H&S §1339.75) — disclosure requirement on GenAI-generated patient-facing clinical communications unless provider-reviewed"
        },
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure — interpretation remains a licensed clinical responsibility",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure — interpretation remains a licensed clinical responsibility",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (in-repo image-selection basis; AI-overread workflow is a generic functional equivalent built for this repo, not reproduced from any vendor)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §2.1 (in-repo image-selection basis; AI-overread workflow is a generic functional equivalent built for this repo, not reproduced from any vendor)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "rad-022",
      "kind": "clinical",
      "materials": [
        "AI radiograph-analysis software output/overlay",
        "chart documentation field for AI-assisted findings"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The software marks suspected caries, bone loss, or other findings directly on the image or in a summary list, before any clinician has reviewed it.\n\nWhy: The AI output is a first-pass screening aid, not a finding — it has not yet been read by a licensed clinician.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "AI software generates flags or an overlay on the acquired image",
          "why": "The AI output is a first-pass screening aid, not a finding — it has not yet been read by a licensed clinician."
        },
        {
          "detail": "No AI-generated flag or overlay is charted as a clinical finding, and none is shown to the patient, until the dentist has personally reviewed the underlying image and either confirms or dismisses each flag.\n\nWhy: AI radiograph analysis is a screening tool; treating an unreviewed flag as a diagnosis would let software make a clinical call it is not licensed to make.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist overread required before any AI flag is charted or shown to the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist overread required before any AI flag is charted or shown to the patient",
          "why": "AI radiograph analysis is a screening tool; treating an unreviewed flag as a diagnosis would let software make a clinical call it is not licensed to make."
        },
        {
          "detail": "For every AI-generated flag, the dentist looks at the underlying radiograph directly (not just the overlay) and decides: confirmed finding, false positive, or needs a second view to resolve.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review each flag against the actual image"
        },
        {
          "detail": "Is the flag a confirmed clinical finding?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "confirmed",
              "label": "Confirmed — chart as a clinical finding"
            },
            {
              "goto": "s8",
              "id": "dismissed",
              "label": "Dismissed as a false positive"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the flag a confirmed clinical finding?"
        },
        {
          "detail": "Document the finding in the chart as the dentist's interpretation, noting that AI-assisted software flagged the area for review — the chart entry is the dentist's clinical conclusion, not a copy of the software output.\n\nRecord: Chart note: finding, tooth/site, dentist's interpretation, note that AI screening assisted.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Chart the finding under the dentist's own clinical judgment"
        },
        {
          "detail": "Will an AI-generated image or overlay be shown to the patient?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-show",
              "label": "Not shown to patient — dentist explains findings verbally instead"
            },
            {
              "goto": "s9",
              "id": "show",
              "label": "AI overlay will be shown to the patient for education/case presentation"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Will an AI-generated image or overlay be shown to the patient?"
        },
        {
          "detail": "AI-assisted radiograph review closed",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "AI-assisted radiograph review closed"
        },
        {
          "detail": "Note false positives internally so the practice can track the AI tool's accuracy over time; this does not go in the patient's clinical chart as a finding.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Log the dismissed flag for software performance tracking"
        },
        {
          "detail": "Before or alongside showing any AI-generated overlay to the patient, state clearly: 'This image marking was AI-generated and has been reviewed by your licensed dentist' (AB 3030 disclosure) — the disclosure accompanies the material, it is not buried in a separate document.\n\nWhy: AB 3030 requires disclosure on GenAI-generated content reaching a patient unless the exemption for provider-reviewed communications applies; reviewing it in the prior gate is what allows this path, but the disclosure is still given.\n\nRecord: Note in chart that the AI overlay was shown with disclosure given.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Disclose the AI-generated nature of the overlay to the patient",
          "why": "AB 3030 requires disclosure on GenAI-generated content reaching a patient unless the exemption for provider-reviewed communications applies; reviewing it in the prior gate is what allows this path, but the disclosure is still given."
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "AI-assisted radiograph analysis: clinician overread before charting or patient display — The practice adopts caries- or pathology-detection software, or an AI overlay is shown to a patient.",
      "title": "AI-assisted radiograph analysis: clinician overread before charting or patient display",
      "trigger": "The practice adopts caries- or pathology-detection software, or an AI overlay is shown to a patient",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure — interpretation and follow-up responsibility",
          "source": "FDA/ADA Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure — interpretation and follow-up responsibility",
          "url": "https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations"
        },
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.524 right of access — the patient's right to their imaging and chart history relevant to disclosure",
          "source": "HIPAA 45 CFR 164.524 right of access — the patient's right to their imaging and chart history relevant to disclosure",
          "url": "https://www.ecfr.gov/current/title-45/part-164"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (in-repo documentation standards — chart note requirements apply to the disclosure entry)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §8.1 (in-repo documentation standards — chart note requirements apply to the disclosure entry)"
        }
      ],
      "class": "radiography-imaging",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "rad-023",
      "kind": "clinical",
      "materials": [
        "prior and current radiographs side by side",
        "chart history",
        "risk-management/malpractice carrier contact",
        "recall/referral scheduling"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Pull the specific prior image and confirm, side by side with the current one, that the finding was genuinely visible at the earlier date and was not a new development.\n\nWhy: Confirming the finding was actually present earlier (not just visible in hindsight with better information) is what distinguishes this from a routine new finding.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the finding is present on the older image",
          "why": "Confirming the finding was actually present earlier (not just visible in hindsight with better information) is what distinguishes this from a routine new finding."
        },
        {
          "detail": "No disclosure, chart note framing, or patient contact happens until the dentist has personally reviewed both images and the chart timeline in full.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating dentist reviews the case before any communication happens.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating dentist reviews the case before any communication happens"
        },
        {
          "detail": "Determine what the delay in identification means clinically for this patient — has the condition progressed, does treatment now differ from what it would have been, is there urgency to today's follow-up.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Assess the clinical significance of the delay"
        },
        {
          "detail": "Inform practice leadership promptly — this is a risk-management matter regardless of how the disclosure conversation ultimately goes.\n\nWhy: Early internal notification, before the patient conversation, is what lets the practice loop in its malpractice carrier or risk-management resource if warranted.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Notify the practice owner and compliance officer",
          "why": "Early internal notification, before the patient conversation, is what lets the practice loop in its malpractice carrier or risk-management resource if warranted."
        },
        {
          "detail": "For findings with real clinical or liability significance, contact the practice's malpractice carrier or risk-management line before the patient conversation happens, per their guidance.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner decides whether to loop in the malpractice carrier or risk-management resource before disclosure.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner decides whether to loop in the malpractice carrier or risk-management resource before disclosure"
        },
        {
          "detail": "Prepare to tell the patient plainly: what was found, that it was visible on an earlier image, what it means for their care now, and what happens next — without minimizing or over-explaining.\n\nWhy: A direct, honest disclosure delivered promptly is both the ethical standard and the best risk-management posture; delay or vagueness compounds the original problem.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare a plain, direct disclosure",
          "why": "A direct, honest disclosure delivered promptly is both the ethical standard and the best risk-management posture; delay or vagueness compounds the original problem."
        },
        {
          "detail": "The treating dentist has this conversation personally, in person or by phone, not by letter alone and not delegated to office staff.\n\nRecord: Chart note: date of disclosure, who was present, what was communicated, patient's response.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Disclose to the patient directly"
        },
        {
          "detail": "Arrange the appropriate next step immediately — recall interval, treatment appointment, or specialist referral — rather than leaving it to the patient to initiate.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Schedule the needed follow-up, treatment, or specialist referral"
        },
        {
          "detail": "Both images, the timeline, disclosure note, risk-management contact (if any), and follow-up plan are filed together in the incident record and the patient's chart.\n\nRecord: Incident record with cross-reference to chart note.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the complete incident record"
        },
        {
          "detail": "Overlooked-finding disclosure and recall closed",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Overlooked-finding disclosure and recall closed"
        }
      ],
      "subclass": "radiography-imaging-and-radiation-safety",
      "summary": "Previously overlooked radiographic finding discovered on later review: disclosure and recall — A lesion or pathology visible on an older image is noticed at a later visit or by a second reader.",
      "title": "Previously overlooked radiographic finding discovered on later review: disclosure and recall",
      "trigger": "A lesion or pathology visible on an older image is noticed at a later visit or by a second reader",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 45,
      "frequency": "daily",
      "id": "rcm-001",
      "kind": "operational",
      "materials": [
        "day's completed procedures list from the practice management system",
        "claim scrub checklist",
        "clinical chart notes for each procedure on the batch",
        "clearinghouse submission queue"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Pull every completed, chart-closed procedure for the day from the practice management system into the pending claim batch.\n\nWhy: A claim can only be scrubbed and reviewed once the full day's completed work is assembled in one place.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Compile the day's completed procedures into a claim batch",
          "why": "A claim can only be scrubbed and reviewed once the full day's completed work is assembled in one place."
        },
        {
          "detail": "Check: patient and subscriber demographics match the payer's file, NPI and tax ID present, procedure codes match the tooth/surface chart, coordination-of-benefits order is correct, and any required attachment is flagged.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Scrub each claim for common errors"
        },
        {
          "detail": "Confirm each CDT code on the claim is supported by the corresponding chart note and matches the tooth number and surfaces documented.\n\nWhy: A code that does not match the documented clinical work is the most common driver of both denials and False Claims Act exposure.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Cross-check procedure codes against the clinical chart notes",
          "why": "A code that does not match the documented clinical work is the most common driver of both denials and False Claims Act exposure."
        },
        {
          "detail": "Does anything need the dentist's input before review — a coding question or a missing attachment?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "clean",
              "label": "Batch is clean, no open questions"
            },
            {
              "goto": "s12",
              "id": "needs-resolution",
              "label": "A coding question or missing attachment must be resolved first"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "billing",
          "title": "Does anything need the dentist's input before review — a coding question or a missing attachment?"
        },
        {
          "detail": "Present the full scrubbed batch, with any resolved questions noted, to the treating dentist for line-by-line review.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Hand the scrubbed batch to the dentist for review"
        },
        {
          "detail": "The dentist reads each line of the batch against the chart, confirming the coded procedures reflect the actual clinical work performed that day.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews each claim against the clinical record"
        },
        {
          "detail": "No claim leaves the practice management system for the clearinghouse until the treating dentist has explicitly attested to the batch — this step is never auto-submitted, regardless of how clean the scrub looked.\n\nWhy: Claim submission is a billing and licensure-consequential act; per the practice's HITL boundary it never proceeds on a staff-level pass alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist attests and signs off before any claim is released.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist attests and signs off before any claim is released",
          "why": "Claim submission is a billing and licensure-consequential act; per the practice's HITL boundary it never proceeds on a staff-level pass alone."
        },
        {
          "detail": "Approve the full batch, or hold specific claims?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "approve-all",
              "label": "Approve the full batch as reviewed"
            },
            {
              "goto": "s13",
              "id": "hold-some",
              "label": "Hold one or more claims for correction"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Approve the full batch, or hold specific claims?"
        },
        {
          "detail": "Submit the dentist-approved claims through the clearinghouse queue within the day's submission window.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Release the approved claims to the clearinghouse"
        },
        {
          "detail": "Log the batch id, claim count, attestation timestamp and submission timestamp in the billing record.\n\nRecord: Batch identifier, claim count, dentist attestation timestamp, and clearinghouse submission timestamp, filed in the billing log.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Log the batch release"
        },
        {
          "detail": "Daily claim batch reviewed, signed off and released",
          "id": "s11",
          "kind": "step",
          "title": "Daily claim batch reviewed, signed off and released"
        },
        {
          "detail": "Route coding questions to the procedure-code-question protocol (rcm-003) and missing attachments to the attachments protocol (rcm-002) before continuing.",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Resolve open coding questions or gather missing attachments"
        },
        {
          "detail": "Note the specific reason for each hold and return those claims to billing to correct before they rejoin a future batch.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Return held claims to billing for correction"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Daily claim batch review, coding accuracy check and licensed sign-off before release — End of each clinical day — the biller scrubs the batch, the dentist reviews and attests, then it is released; never auto-submitted.",
      "title": "Daily claim batch review, coding accuracy check and licensed sign-off before release",
      "trigger": "End of each clinical day — the biller scrubs the batch, the dentist reviews and attests, then it is released; never auto-submitted",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "rcm-002",
      "kind": "operational",
      "materials": [
        "payer attachment requirements reference",
        "radiograph/photo export tool",
        "perio chart export",
        "narrative template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "assistant",
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the payer's attachment requirements reference for the specific procedure code to determine whether a radiograph, photo, perio chart, or written narrative is required.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Identify which attachment or narrative this payer requires for the procedure"
        },
        {
          "detail": "Does this claim need a radiograph/photo, a perio chart, a narrative, or a combination?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "images-only",
              "label": "Radiograph or intraoral photo only"
            },
            {
              "goto": "s10",
              "id": "perio-only",
              "label": "Perio chart export only"
            },
            {
              "goto": "s4",
              "id": "narrative-needed",
              "label": "Written narrative is required (with or without images)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does this claim need a radiograph/photo, a perio chart, a narrative, or a combination?"
        },
        {
          "detail": "Pull the specific pre-treatment or diagnostic image from the imaging system that documents the condition being treated.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Export the relevant radiograph or intraoral photo"
        },
        {
          "detail": "Write a short narrative describing the clinical finding and why the coded procedure was necessary, drawing directly from the chart note.\n\nWhy: A narrative must reflect only what is documented in the chart — inventing or exaggerating clinical necessity is what turns a claim into a false claim.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Draft the medical-necessity narrative in plain clinical language",
          "why": "A narrative must reflect only what is documented in the chart — inventing or exaggerating clinical necessity is what turns a claim into a false claim."
        },
        {
          "detail": "The treating dentist reads the drafted narrative against the chart and approves it, or edits it, before it is allowed to attach — billing staff never finalize medical-necessity language alone.\n\nWhy: The narrative asserts a clinical judgment; only the licensed provider who made that judgment can attest it is accurate.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and approves the narrative before it attaches to the claim.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and approves the narrative before it attaches to the claim",
          "why": "The narrative asserts a clinical judgment; only the licensed provider who made that judgment can attest it is accurate."
        },
        {
          "detail": "Attach the approved images, perio data and narrative to the specific claim line in the practice management system.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Attach the approved documentation to the claim"
        },
        {
          "detail": "Check: every required attachment type for this payer and procedure is present, images are legible, narrative is signed off, and the claim is unblocked for the next batch review.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Verify the attachment package matches the payer's requirement"
        },
        {
          "detail": "Log the claim reference, attachment types, narrative approver and date with the claim record.\n\nRecord: Claim reference, attachment types included, narrative approver, and date, filed with the claim record.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Log the attachment package"
        },
        {
          "detail": "Attachment and narrative package complete and ready for batch review",
          "id": "s9",
          "kind": "step",
          "title": "Attachment and narrative package complete and ready for batch review"
        },
        {
          "detail": "Pull the pocket depths, bleeding points and recession measurements from the chart that support the coded periodontal procedure.",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Export the relevant perio charting"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Claim attachments, narratives and medical-necessity documentation (radiographs, perio charts, photos) — A procedure on today's batch requires an attachment or narrative for a reviewable service.",
      "title": "Claim attachments, narratives and medical-necessity documentation (radiographs, perio charts, photos)",
      "trigger": "A procedure on today's batch requires an attachment or narrative for a reviewable service",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "rcm-003",
      "kind": "operational",
      "materials": [
        "current CDT code reference",
        "the ambiguous chart note",
        "code-question log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Mark the specific procedure line where the chart note does not clearly map to a single CDT code, and note what makes it ambiguous.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Flag the claim line where the code is unclear"
        },
        {
          "detail": "Does the current CDT code reference resolve the ambiguity on its own?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "resolved-by-reference",
              "label": "Reference clarifies the correct code"
            },
            {
              "goto": "s6",
              "id": "still-ambiguous",
              "label": "Still unclear — needs the dentist's clinical judgment"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "Does the current CDT code reference resolve the ambiguity on its own?"
        },
        {
          "detail": "Log the final code, resolver and any chart amendment reference against the claim line.\n\nRecord: Final procedure code, who resolved it, and any chart amendment reference, logged against the claim line.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Record the resolved code and rationale"
        },
        {
          "detail": "Rejoin the corrected claim line to the day's claim batch for the standard scrub-and-review flow.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Return the resolved claim line to the daily batch"
        },
        {
          "detail": "Procedure code question resolved",
          "id": "s5",
          "kind": "step",
          "title": "Procedure code question resolved"
        },
        {
          "detail": "Send the flagged claim line, the chart note, and the specific coding question to the dentist for a decision.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Route the question to the treating dentist"
        },
        {
          "detail": "The dentist reviews the note and states the correct code — billing never guesses or defaults on an ambiguous clinical code.\n\nWhy: Selecting the procedure code is a clinical judgment about what was actually performed, which only the treating provider can make.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist makes the coding determination.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist makes the coding determination",
          "why": "Selecting the procedure code is a clinical judgment about what was actually performed, which only the treating provider can make."
        },
        {
          "detail": "Does the chart note need to be amended to support the chosen code?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "note-sufficient",
              "label": "Existing note already supports the code"
            },
            {
              "goto": "s9",
              "id": "amend-note",
              "label": "Note should be amended for clarity"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the chart note need to be amended to support the chosen code?"
        },
        {
          "detail": "Add a dated addendum to the original note clarifying the clinical detail that supports the chosen code; the original entry is never deleted.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist amends the chart note as a dated addendum"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Procedure-code question escalated to the dentist — The biller is unsure which procedure code matches the clinical note — the dentist decides and the note is amended if needed.",
      "title": "Procedure-code question escalated to the dentist",
      "trigger": "The biller is unsure which procedure code matches the clinical note — the dentist decides and the note is amended if needed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 20,
      "frequency": "daily",
      "id": "rcm-004",
      "kind": "operational",
      "materials": [
        "clearinghouse rejection report",
        "payer edit/rejection code reference",
        "practice management system claim editor"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Download or open the current rejection report listing every claim the clearinghouse could not forward to the payer.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Pull the day's clearinghouse rejection report"
        },
        {
          "detail": "Read each rejection code and sort into a category: demographic mismatch, invalid payer ID, missing NPI, format error, or duplicate submission.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Categorize each rejection by root cause"
        },
        {
          "detail": "Can this rejection be corrected with information already on file?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "fixable",
              "label": "Correctable now with information on file"
            },
            {
              "goto": "s8",
              "id": "needs-more-info",
              "label": "Needs more information (e.g. updated subscriber ID from the patient)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Can this rejection be corrected with information already on file?"
        },
        {
          "detail": "Fix the identified field — demographic, payer ID, NPI, or format — and resubmit the claim through the clearinghouse the same day.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Correct the claim and resubmit"
        },
        {
          "detail": "Log the claim reference, rejection category, correction applied and resubmission date.\n\nRecord: Claim reference, rejection reason category, correction applied or information requested, and resubmission date, filed in the rejection log.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Log the rejection and its outcome"
        },
        {
          "detail": "Has this exact rejection type recurred repeatedly this week?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-pattern",
              "label": "No recurring pattern"
            },
            {
              "goto": "s9",
              "id": "pattern-found",
              "label": "Same rejection type recurring"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "billing",
          "title": "Has this exact rejection type recurred repeatedly this week?"
        },
        {
          "detail": "Rejection report worked up for the day",
          "id": "s7",
          "kind": "step",
          "title": "Rejection report worked up for the day"
        },
        {
          "detail": "Contact the patient or payer for the missing data point needed to correct the claim, and hold the claim pending that response.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Request the missing information"
        },
        {
          "detail": "Flag the recurring rejection type to the office manager so the upstream cause (intake form, PMS default, or payer setup) can be fixed at the source.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Escalate the recurring rejection pattern"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Clearinghouse rejection workup (same day) — The clearinghouse rejection report arrives.",
      "title": "Clearinghouse rejection workup (same day)",
      "trigger": "The clearinghouse rejection report arrives",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 30,
      "frequency": "daily",
      "id": "rcm-005",
      "kind": "operational",
      "materials": [
        "ERA file or paper EOB",
        "current PPO fee schedule per payer",
        "practice management system payment posting screen"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Import the ERA file into the practice management system, or open the paper EOB for manual entry.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Receive the electronic remittance or paper EOB"
        },
        {
          "detail": "Confirm each paid, denied, or adjusted line on the remittance corresponds to the correct outstanding claim in the system.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Match each payment line to its originating claim"
        },
        {
          "detail": "Does the paid amount plus the contractual adjustment match the fee schedule for this payer?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "matches",
              "label": "Matches the fee schedule as expected"
            },
            {
              "goto": "s8",
              "id": "variance",
              "label": "Paid amount or adjustment does not match the fee schedule"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Does the paid amount plus the contractual adjustment match the fee schedule for this payer?"
        },
        {
          "detail": "Post the paid amount to the claim, post the contractual adjustment as a write-off against the fee schedule difference, and leave any true balance for the next stage.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Post the payment and contractual write-off"
        },
        {
          "detail": "Does this line carry a denial code, or a patient-responsibility balance?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "clean-close",
              "label": "Fully paid and closed, no denial, no patient balance"
            },
            {
              "goto": "s11",
              "id": "has-denial",
              "label": "Carries a denial reason code"
            },
            {
              "goto": "s12",
              "id": "patient-balance",
              "label": "Leaves a patient-responsibility balance"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "billing",
          "title": "Does this line carry a denial code, or a patient-responsibility balance?"
        },
        {
          "detail": "Log the claim reference, amount paid, adjustment amount, routing decision and posting date in the payment ledger.\n\nRecord: Claim reference, amount paid, contractual adjustment amount, denial or balance routing, and posting date, filed in the payment ledger.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Log the posting"
        },
        {
          "detail": "Remittance posted and reconciled",
          "id": "s7",
          "kind": "step",
          "title": "Remittance posted and reconciled"
        },
        {
          "detail": "Compare the remittance line against the current signed fee schedule for that payer; determine whether the fee schedule on file is outdated or the payer underpaid.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Investigate the variance before posting"
        },
        {
          "detail": "Is the fee schedule on file outdated, or did the payer underpay against a correct table?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "stale-schedule",
              "label": "Fee schedule on file is outdated"
            },
            {
              "goto": "s13",
              "id": "payer-underpaid",
              "label": "Payer paid less than the correct contracted amount"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "billing",
          "title": "Is the fee schedule on file outdated, or did the payer underpay against a correct table?"
        },
        {
          "detail": "Update the fee schedule table to the payer's current contracted rates, then re-verify this remittance line against the corrected table before posting.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Correct the fee schedule table before posting"
        },
        {
          "detail": "Send the denied claim line to the claim denial workup protocol (rcm-007) for root-cause review and correction or appeal.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Route the denied line to the denial workup protocol"
        },
        {
          "detail": "Move the patient-responsibility balance into the next statement cycle.",
          "id": "s12",
          "kind": "step",
          "role": "billing",
          "title": "Route the remaining balance to patient statement processing"
        },
        {
          "detail": "Post only the amount the payer actually paid; do not post the underpaid shortfall as a contractual write-off or a patient-responsibility balance, since it reflects a payer underpayment against a correct fee schedule, not an adjustment owed by the patient.\n\nWhy: Treating a payer's underpayment as a patient balance is the exact balance-billing risk this class polices — the shortfall belongs with the payer, not the patient.",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "Post only the amount actually paid, never the shortfall as a patient balance",
          "why": "Treating a payer's underpayment as a patient balance is the exact balance-billing risk this class polices — the shortfall belongs with the payer, not the patient."
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "ERA/EOB payment posting and contractual adjustment — An electronic remittance or paper EOB is received.",
      "title": "ERA/EOB payment posting and contractual adjustment",
      "trigger": "An electronic remittance or paper EOB is received",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 25,
      "frequency": "daily",
      "id": "rcm-006",
      "kind": "operational",
      "materials": [
        "practice management system day sheet",
        "cash/check/card payment log",
        "deposit slip",
        "reconciliation checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Sum cash, check, and card payments received during the day from the front-desk payment log.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Total the day's payments by type"
        },
        {
          "detail": "Pull the system-generated day sheet and compare its payment totals by type against the manually totaled payment log.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Compare the totals to the practice management system day sheet"
        },
        {
          "detail": "Do the day sheet and the payment log match?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "matches",
              "label": "Totals match exactly"
            },
            {
              "goto": "s9",
              "id": "variance-found",
              "label": "A variance is found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Do the day sheet and the payment log match?"
        },
        {
          "detail": "Prepare the deposit slip for cash and checks matching the reconciled totals.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Prepare the deposit slip"
        },
        {
          "detail": "A staff member who did not perform the initial count independently verifies the day sheet, payment log, and deposit slip agree before the day is marked closed.\n\nWhy: Two-person control on cash handling is a standard internal-control safeguard against both error and misappropriation — a generic front-office/finance practice this protocol applies to dental billing, not drawn from a dental-specific statute.",
          "gate": {
            "ack": "I confirm I have completed this step as written: A second person verifies the reconciliation before the day is closed.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "A second person verifies the reconciliation before the day is closed",
          "why": "Two-person control on cash handling is a standard internal-control safeguard against both error and misappropriation — a generic front-office/finance practice this protocol applies to dental billing, not drawn from a dental-specific statute."
        },
        {
          "detail": "Finalize and lock the day sheet in the system so no further entries can post to that date without a documented correction.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Close the day sheet in the practice management system"
        },
        {
          "detail": "Log the date, totals by type, variance and resolution, and both staff names in the daily close log.\n\nRecord: Date, totals by payment type, any variance found and its resolution, first-counter and second-verifier names, filed in the daily close log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the reconciliation and close"
        },
        {
          "detail": "Day closed with two-person reconciliation complete",
          "id": "s8",
          "kind": "step",
          "title": "Day closed with two-person reconciliation complete"
        },
        {
          "detail": "Trace the discrepancy to a specific transaction — a missed entry, a duplicate, or a posting error — and correct it, or document why it cannot be resolved same day.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Investigate the variance before closing the day"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Daily deposit and day-sheet close with two-person reconciliation — End of day — payments by type reconciled to the deposit and the practice software day sheet, a second person verifies.",
      "title": "Daily deposit and day-sheet close with two-person reconciliation",
      "trigger": "End of day — payments by type reconciled to the deposit and the practice software day sheet, a second person verifies",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "rcm-007",
      "kind": "operational",
      "materials": [
        "denial reason code reference",
        "original claim and supporting documentation",
        "payer's timely-filing and appeal-window reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "office-manager",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Open the remittance line and read the specific denial or adjustment reason code the payer returned.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Read the denial reason code"
        },
        {
          "detail": "Determine whether the denial stems from a data error, missing documentation, a coverage exclusion, frequency limitation, or a medical-necessity determination.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Identify the root cause behind the denial"
        },
        {
          "detail": "Is this a fixable error, or a substantive denial to appeal?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "fixable-error",
              "label": "Fixable data or documentation error"
            },
            {
              "goto": "s11",
              "id": "substantive-denial",
              "label": "Substantive denial (coverage, necessity, frequency) — needs an appeal"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Is this a fixable error, or a substantive denial to appeal?"
        },
        {
          "detail": "Fix the identified demographic or missing-documentation error, or identify that the fix requires changing the billed procedure code, and prepare the corrected claim for resubmission.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Prepare the corrected claim"
        },
        {
          "detail": "Does this correction change the billed procedure code, or only demographic/documentation fields?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "demographic-or-documentation",
              "label": "Demographic or documentation fields only — no code change"
            },
            {
              "goto": "s12",
              "id": "coding-change",
              "label": "Correction changes the billed procedure code"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "billing",
          "title": "Does this correction change the billed procedure code, or only demographic/documentation fields?"
        },
        {
          "detail": "A second, more senior biller or the office manager reviews the corrected claim against the original denial reason before it is resubmitted — corrections are never resubmitted on the same person's own unreviewed judgment.\n\nWhy: A misdiagnosed root cause resubmitted without a second look produces the same denial again and delays payment further.",
          "gate": {
            "ack": "I confirm I have completed this step as written: A billing supervisor reviews the correction before resubmission.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "office-manager",
          "title": "A billing supervisor reviews the correction before resubmission",
          "why": "A misdiagnosed root cause resubmitted without a second look produces the same denial again and delays payment further."
        },
        {
          "detail": "Check: the corrected claim will be resubmitted before the payer's timely-filing deadline expires; if close to the deadline, flag for same-day resubmission.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Confirm the correction is within the payer's timely-filing window"
        },
        {
          "detail": "Submit the corrected claim through the clearinghouse and mark the original claim as superseded in the system.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Resubmit the corrected claim"
        },
        {
          "detail": "Log the denial reason, root cause, correction, reviewer and resubmission date in the denial log.\n\nRecord: Original denial reason, root cause identified, correction made, reviewer, and resubmission date, filed in the denial log.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Log the denial workup and outcome"
        },
        {
          "detail": "Denial worked up and resolved by correction or routed to appeal",
          "id": "s10",
          "kind": "step",
          "title": "Denial worked up and resolved by correction or routed to appeal"
        },
        {
          "detail": "Send the denial, along with the root-cause finding, to the claim appeal protocol (rcm-008) for dentist-reviewed appeal preparation.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Route to the claim appeal protocol"
        },
        {
          "detail": "Route the proposed code change through the procedure-code-question protocol (rcm-003) so the treating dentist, not billing staff, makes the coding determination before the corrected claim is resubmitted.\n\nWhy: Selecting the procedure code is a clinical judgment only the treating provider can make (rcm-003); a denial correction that changes the code cannot bypass that same rule.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the corrected procedure code before resubmission.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the corrected procedure code before resubmission",
          "why": "Selecting the procedure code is a clinical judgment only the treating provider can make (rcm-003); a denial correction that changes the code cannot bypass that same rule."
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Claim denial workup and corrected claim — A denial posts — reason code read, root cause fixed, corrected claim or appeal chosen.",
      "title": "Claim denial workup and corrected claim",
      "trigger": "A denial posts — reason code read, root cause fixed, corrected claim or appeal chosen",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "statute",
          "label": "California SB 1120 (H&S §1367.01) — binds health care service plans and disability insurers doing utilization review; cited only in the insurer-appeal context, never as a practice-software obligation",
          "source": "California SB 1120 (H&S §1367.01) — binds health care service plans and disability insurers doing utilization review; cited only in the insurer-appeal context, never as a practice-software obligation",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=1367.01"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "rcm-008",
      "kind": "operational",
      "materials": [
        "original claim and denial notice",
        "supporting clinical documentation (chart notes, images, perio data)",
        "payer's appeal submission process and deadlines",
        "appeal narrative template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Review the denial reason and determine whether the appeal challenges a coverage determination, a frequency limitation, or a medical-necessity finding from the payer's utilization review.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm the basis for the appeal"
        },
        {
          "detail": "Compile the chart notes, radiographs, perio data, and any prior authorization or attachment already on file that supports the medical necessity of the denied procedure.",
          "id": "s2",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Gather the supporting clinical documentation for the appeal"
        },
        {
          "detail": "Write the clinical rationale for the appeal, referencing the specific documentation gathered and, where the denial came from a health plan's or insurer's utilization review, note that the plan's review is governed by California SB 1120 (H&S §1367.01) as the payer's own regulatory obligation — not a claim about the practice's software.\n\nWhy: SB 1120 binds the health plan or insurer performing utilization review, not the dental practice; the appeal correctly cites it as the payer's obligation to support the argument, never as something the practice itself must comply with.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Draft the appeal narrative",
          "why": "SB 1120 binds the health plan or insurer performing utilization review, not the dental practice; the appeal correctly cites it as the payer's obligation to support the argument, never as something the practice itself must comply with."
        },
        {
          "detail": "The treating dentist reads the full appeal narrative and supporting documentation and signs it — an appeal asserting clinical necessity is never submitted on staff judgment alone.\n\nWhy: The appeal makes a clinical necessity argument on the dentist's behalf; only the licensed provider can attest that argument is accurate.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs the appeal narrative before submission.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs the appeal narrative before submission",
          "why": "The appeal makes a clinical necessity argument on the dentist's behalf; only the licensed provider can attest that argument is accurate."
        },
        {
          "detail": "Does the appeal need the patient's input or signature (e.g. an authorization or a statement of symptoms)?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-patient-input",
              "label": "No patient input needed"
            },
            {
              "goto": "s12",
              "id": "needs-patient-input",
              "label": "Patient input or signature needed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does the appeal need the patient's input or signature (e.g. an authorization or a statement of symptoms)?"
        },
        {
          "detail": "Submit the complete, signed appeal packet through the payer's required channel before the applicable appeal deadline.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Submit the appeal within the payer's window"
        },
        {
          "detail": "Log the denial reason, appeal level, signer, submission date and payer deadline in the appeal log.\n\nRecord: Original denial reason, appeal level (first or second), dentist signer, submission date, and payer deadline, filed in the appeal log.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Log the appeal submission"
        },
        {
          "detail": "Set a follow-up reminder for the payer's stated appeal response timeframe (commonly around 30 days) so a non-response can be escalated rather than silently dropped; adjust to the specific deadline the payer stated for this appeal.",
          "id": "s8",
          "kind": "timer",
          "role": "billing",
          "timer_seconds": 2592000,
          "title": "Track the payer's response window"
        },
        {
          "detail": "How did the payer respond?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "overturned",
              "label": "Appeal overturned — claim will be paid"
            },
            {
              "goto": "s13",
              "id": "upheld-first-level",
              "label": "Upheld at first level — escalate to second-level appeal"
            },
            {
              "goto": "s14",
              "id": "upheld-final",
              "label": "Upheld at final level — no further appeal available"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "billing",
          "title": "How did the payer respond?"
        },
        {
          "detail": "Log the final determination, date and downstream routing in the appeal log.\n\nRecord: Final determination, date, and downstream routing (paid, second-level appeal, or write-off/patient balance), filed in the appeal log.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Log the final appeal outcome"
        },
        {
          "detail": "Appeal resolved to a final outcome",
          "id": "s11",
          "kind": "step",
          "title": "Appeal resolved to a final outcome"
        },
        {
          "detail": "Contact the patient to obtain the specific authorization, statement, or signature the appeal requires, and attach it to the packet.",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Obtain the needed patient input or signature"
        },
        {
          "detail": "Repeat the narrative drafting and dentist sign-off gate for a second-level appeal, adding any new documentation available.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare and submit the second-level appeal"
        },
        {
          "detail": "Hand the finally-denied balance to the practice's write-off or patient-statement process, as appropriate.",
          "id": "s14",
          "kind": "step",
          "role": "billing",
          "title": "Route the final outcome to write-off or patient balance handling"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Claim appeal to the payer (first and second level), including a plan's utilization-review denial — A denial is believed incorrect or a payer denied on medical-necessity grounds — the dentist reviews and signs the appeal narrative; where a health plan's or insurer's AI-assisted utilization review is involved, California SB 1120 binds that plan's review and is cited in the appeal.",
      "title": "Claim appeal to the payer (first and second level), including a plan's utilization-review denial",
      "trigger": "A denial is believed incorrect or a payer denied on medical-necessity grounds — the dentist reviews and signs the appeal narrative; where a health plan's or insurer's AI-assisted utilization review is involved, California SB 1120 binds that plan's review and is cited in the appeal",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "regulation",
          "label": "Coordination of Benefits (COB) model regulation — NAIC",
          "source": "Coordination of Benefits (COB) model regulation — NAIC",
          "url": "https://content.naic.org/"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "rcm-009",
      "kind": "operational",
      "materials": [
        "primary EOB/ERA",
        "secondary plan coordination-of-benefits record",
        "clearinghouse portal",
        "837D claim form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the account's coordination-of-benefits record for an active secondary carrier before doing anything else.\n\nWhy: If no secondary is on file the claim never gets submitted and the balance sits on the patient by mistake.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Confirm a secondary plan is on file for the patient",
          "why": "If no secondary is on file the claim never gets submitted and the balance sits on the patient by mistake."
        },
        {
          "detail": "COB rules (birthday rule, custody order, etc.) decide primary vs secondary; confirm it matches what was billed.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "COB confirmed, matches billed order"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "COB unclear or conflicting"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "Is coordination of benefits (which plan pays first) already confirmed?"
        },
        {
          "detail": "Pull the primary carrier's EOB/ERA showing allowed amount, paid amount and patient responsibility, and attach it to the secondary claim per the 837D attachment format.\n\nWhy: Every dental plan requires proof of the primary's adjudication before it will pay as secondary.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Attach the primary EOB/ERA to the secondary claim",
          "why": "Every dental plan requires proof of the primary's adjudication before it will pay as secondary."
        },
        {
          "detail": "Enter the primary allowed amount, primary paid amount and any contractual write-off in the secondary claim's other-coverage fields.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Populate the secondary claim with the primary's paid and adjusted amounts"
        },
        {
          "detail": "Confirm: secondary member ID current, procedure codes match the primary claim, primary EOB attached, patient responsibility amount matches the ledger.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Pre-submission checklist for the secondary claim"
        },
        {
          "detail": "Submit electronically via the clearinghouse; if the secondary payer does not accept electronic secondary claims, mail a paper claim with the EOB attached.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Submit the secondary claim through the clearinghouse"
        },
        {
          "detail": "Date submitted, submission method, secondary claim/tracking number, and expected response window on the account ledger.\n\nRecord: Date submitted, submission method, secondary claim/tracking number, and expected response window on the account ledger.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Log the secondary submission on the account"
        },
        {
          "detail": "Hold the account in a secondary-pending queue for the payer's typical processing window (about 3 weeks) before following up.",
          "id": "s8",
          "kind": "timer",
          "role": "billing",
          "timer_seconds": 1814400,
          "title": "Wait for the secondary carrier's response"
        },
        {
          "detail": "Did the secondary carrier respond within the expected window?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "paid",
              "label": "Secondary EOB/ERA received"
            },
            {
              "goto": "s13",
              "id": "silent",
              "label": "No response after the expected window"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "billing",
          "title": "Did the secondary carrier respond within the expected window?"
        },
        {
          "detail": "Post the secondary payment and any remaining contractual adjustment per protocol rcm-005; move any true patient balance to statement.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Post the secondary payment and close the claim leg"
        },
        {
          "detail": "Secondary claim cycle complete",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Secondary claim cycle complete"
        },
        {
          "detail": "Send the account to the insurance coordinator with both plans' member IDs and the COB question noted.\n\nWhy: Submitting to the wrong payer as primary causes an automatic denial and delays payment further.",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand off to the insurance coordinator to verify COB with both carriers",
          "why": "Submitting to the wrong payer as primary causes an automatic denial and delays payment further."
        },
        {
          "detail": "If no response arrives within the expected window, place the claim in the follow-up queue covered by protocol rcm-010 rather than letting it go stale.",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "Route to the aging follow-up queue"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Secondary claim submission after primary pays — The primary EOB is posted and a secondary plan is on file.",
      "title": "Secondary claim submission after primary pays",
      "trigger": "The primary EOB is posted and a secondary plan is on file",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 90,
      "frequency": "weekly",
      "id": "rcm-010",
      "kind": "operational",
      "materials": [
        "practice-management aging report (0-30/31-60/61-90/90+ buckets)",
        "payer timely-filing limit reference table",
        "clearinghouse claim-status portal",
        "payer phone/portal contacts"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Run the practice-management aging report sorted by payer and days outstanding (0-30, 31-60, 61-90, 90+).",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Pull the current claims aging report"
        },
        {
          "detail": "Cross-reference each unsent or rejected claim's date of service against that payer's timely-filing limit (commonly 90 days to 12 months, payer-specific); flag any within 2 weeks of the deadline.\n\nWhy: A claim that misses the filing deadline is permanently unpayable — this is the one error that cannot be corrected later, so it is checked before ordinary aging follow-up.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Sort claims by timely-filing risk first",
          "why": "A claim that misses the filing deadline is permanently unpayable — this is the one error that cannot be corrected later, so it is checked before ordinary aging follow-up."
        },
        {
          "detail": "Any claim within 2 weeks of its timely-filing deadline?",
          "forks": [
            {
              "goto": "s9",
              "id": "urgent",
              "label": "Yes — filing-deadline risk found"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "none",
              "label": "No urgent filing-deadline risk today"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Any claim within 2 weeks of its timely-filing deadline?"
        },
        {
          "detail": "For each claim 31-60 days old: check clearinghouse status, call or check the payer portal if status is unclear, note the payer's stated processing timeline.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Work the 31-60 day bucket"
        },
        {
          "detail": "For each claim over 60 days: call the payer, get a reference number for the call, and get either a payment date or a denial reason in writing.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Work the 61-90 and 90+ day buckets"
        },
        {
          "detail": "What did the payer contact reveal for each aged claim?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "processing",
              "label": "Still processing, payment date given"
            },
            {
              "goto": "s10",
              "id": "denied",
              "label": "Denied or rejected"
            },
            {
              "goto": "s11",
              "id": "lost",
              "label": "Payer has no record of the claim"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "billing",
          "title": "What did the payer contact reveal for each aged claim?"
        },
        {
          "detail": "Claims worked, claims resolved, claims escalated to denial workup, and any timely-filing saves, on the weekly AR tracking log.\n\nRecord: Claims worked, claims resolved, claims escalated to denial workup, and any timely-filing saves, on the weekly AR tracking log.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Log this week's aging sweep results"
        },
        {
          "detail": "Weekly aging sweep complete",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Weekly aging sweep complete"
        },
        {
          "detail": "Correct and resubmit, or submit for the first time, any claim approaching its filing deadline before doing routine aging work.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Submit or resubmit the at-risk claim same day"
        },
        {
          "detail": "Route any claim denied or rejected during this sweep to protocol rcm-007 (denial workup) rather than resolving it inline here.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Hand off denied/rejected claims to the denial workup protocol"
        },
        {
          "detail": "Resubmit through the clearinghouse and note the resubmission on the account; re-flag against the timely-filing deadline.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Resubmit the claim the payer has no record of"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Outstanding claims follow-up (over 30 days) and timely-filing deadline monitor — Weekly aging run — every claim past 30 days is traced with the payer, and unsent or rejected claims approaching the payer's filing limit are swept.",
      "title": "Outstanding claims follow-up (over 30 days) and timely-filing deadline monitor",
      "trigger": "Weekly aging run — every claim past 30 days is traced with the payer, and unsent or rejected claims approaching the payer's filing limit are swept",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692c-1692g — required disclosures and prohibited practices in debt-related communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692c-1692g — required disclosures and prohibited practices in debt-related communications",
          "url": "https://www.consumerfinance.gov/rules-policy/regulations/1006/"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 120,
      "frequency": "monthly",
      "id": "rcm-011",
      "kind": "operational",
      "materials": [
        "practice-management statement-run tool",
        "AR aging report",
        "statement template",
        "balance-due message template (AI-drafted, human-reviewed)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Filter the statement run to exclude any account where a claim is still pending, so patients are not statemented for a balance insurance may still cover.\n\nWhy: Statementing before adjudication finishes generates confusing, sometimes incorrect balances and erodes trust.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Confirm every account has finished insurance adjudication",
          "why": "Statementing before adjudication finishes generates confusing, sometimes incorrect balances and erodes trust."
        },
        {
          "detail": "Run the statement batch for every account with a true patient-responsibility balance above the practice's minimum-to-statement threshold.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Generate the statement batch from the AR aging report"
        },
        {
          "detail": "Use the AI drafting tool to generate a plain-language balance-due message for each account from the statement data. Every AI-drafted message is labeled in the account record as 'AI-drafted — staff-reviewed before send,' the AB 3030-aligned disclosure this practice uses for AI-generated patient billing text.\n\nWhy: AB 3030 disclosure discipline: any AI-generated content a patient will see carries a plain disclosure and is reviewed by a human before it reaches them, and that review is recorded.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Draft the balance-due reminder message with AI assistance",
          "why": "AB 3030 disclosure discipline: any AI-generated content a patient will see carries a plain disclosure and is reviewed by a human before it reaches them, and that review is recorded."
        },
        {
          "detail": "The billing lead reads each AI-drafted balance-due message against the account ledger for accuracy before any statement goes out, confirms the 'AI-drafted — staff-reviewed before send' (AB 3030) disclosure is attached, and edits or rewrites incorrect or unclear drafts by hand.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Human review of AI-drafted statement messaging before send.",
            "role": "billing lead / office manager",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "billing",
          "title": "Human review of AI-drafted statement messaging before send"
        },
        {
          "detail": "Send approved statements by the practice's chosen channel (mail, patient portal, or email) per the account's stated communication preference.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Send the statement batch"
        },
        {
          "detail": "Statement run date, number of statements sent, total dollar amount statemented, and confirmation the AI-drafted messaging review gate was completed.\n\nRecord: Statement run date, number of statements sent, total dollar amount statemented, and confirmation the AI-drafted messaging review gate was completed.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Log the statement run"
        },
        {
          "detail": "Hold statemented accounts for roughly 2 weeks to allow mailed or portal statements to reach the patient and be paid.",
          "id": "s7",
          "kind": "timer",
          "role": "billing",
          "timer_seconds": 1296000,
          "title": "Wait through the payment response window"
        },
        {
          "detail": "Did the patient pay, dispute, or stay silent?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "paid",
              "label": "Payment received"
            },
            {
              "goto": "s10",
              "id": "dispute",
              "label": "Patient disputes the balance"
            },
            {
              "goto": "s11",
              "id": "silent",
              "label": "No response"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "billing",
          "title": "Did the patient pay, dispute, or stay silent?"
        },
        {
          "detail": "Statement cycle complete",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Statement cycle complete"
        },
        {
          "detail": "Route the account to protocol rcm-012 (patient balance dispute) rather than resolving the dispute inline in the statement cycle.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Hand off disputed balances to the dispute protocol"
        },
        {
          "detail": "If unpaid after two statement cycles, move the account toward protocol rcm-013 (past-due collections escalation) at the appropriate aging bucket.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Queue the account for the next statement cycle or collections track"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Patient statement cycle and balance-due messaging — The monthly statement run (or cycle billing) after insurance adjudication.",
      "title": "Patient statement cycle and balance-due messaging",
      "trigger": "The monthly statement run (or cycle billing) after insurance adjudication",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rcm-012",
      "kind": "operational",
      "materials": [
        "account ledger",
        "signed treatment estimate / consent",
        "insurance EOB history",
        "call/contact log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "treatment-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Capture exactly which charge, date of service, or amount the patient is disputing, without agreeing or disagreeing yet.\n\nWhy: Recording the specific complaint before investigating prevents miscommunication and gives a paper trail if the dispute escalates.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Listen to the patient's dispute and log the specifics",
          "why": "Recording the specific complaint before investigating prevents miscommunication and gives a paper trail if the dispute escalates."
        },
        {
          "detail": "Gather the signed treatment estimate/consent, the claim and EOB history, and the current ledger for the disputed date of service.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Pull the account ledger, signed estimate, and insurance history"
        },
        {
          "detail": "Does the charge match the signed estimate and insurance adjudication?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "matches",
              "label": "Charge is correct and documented"
            },
            {
              "goto": "s8",
              "id": "error",
              "label": "A billing or posting error is found"
            },
            {
              "goto": "s11",
              "id": "unclear",
              "label": "Not clear from the record alone"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Does the charge match the signed estimate and insurance adjudication?"
        },
        {
          "detail": "Walk the patient through the signed estimate, what insurance paid, and how the balance was calculated, and offer copies on request.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Explain the charge with the documentation"
        },
        {
          "detail": "Is the patient satisfied with the explanation or correction?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "resolved",
              "label": "Yes — dispute resolved"
            },
            {
              "goto": "s12",
              "id": "escalate",
              "label": "No — patient wants to escalate further"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "patient",
          "title": "Is the patient satisfied with the explanation or correction?"
        },
        {
          "detail": "Date, nature of the dispute, findings, any adjustment made and who approved it, and the final resolution communicated to the patient.\n\nRecord: Date, nature of the dispute, findings, any adjustment made and who approved it, and the final resolution communicated to the patient.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Document the dispute outcome on the account"
        },
        {
          "detail": "Balance dispute closed",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Balance dispute closed"
        },
        {
          "detail": "Fix the posting error (wrong code, misapplied payment, duplicate charge, etc.) and recalculate the balance.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Correct the identified error"
        },
        {
          "detail": "The office manager reviews and approves any correction, credit, or write-off resulting from the dispute before it posts to the account.\n\nWhy: Any adjustment to a patient balance is a financial control point — it is never made unilaterally by the person who fielded the call.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor sign-off before any balance adjustment posts.",
            "role": "office manager",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor sign-off before any balance adjustment posts",
          "why": "Any adjustment to a patient balance is a financial control point — it is never made unilaterally by the person who fielded the call."
        },
        {
          "detail": "Post the corrected balance and send the patient written confirmation of the correction and the new balance.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Post the approved adjustment and notify the patient"
        },
        {
          "detail": "If the dispute concerns what treatment was planned or performed, hand off to the treatment coordinator (or dentist) to confirm the clinical record before continuing.",
          "id": "s11",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to the treatment coordinator for a clinical-plan question"
        },
        {
          "detail": "If the patient remains unsatisfied after supervisor review, the practice owner reviews the full documentation and makes the final decision, including any goodwill adjustment.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the practice owner for final review"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Patient disputes a balance — A patient calls or writes contesting a charge, the insurance estimate, or a collection account.",
      "title": "Patient disputes a balance",
      "trigger": "A patient calls or writes contesting a charge, the insurance estimate, or a collection account",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — validation notice and permissible contact rules applicable once an account is placed for collection",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — validation notice and permissible contact rules applicable once an account is placed for collection",
          "url": "https://www.consumerfinance.gov/rules-policy/regulations/1006/"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "rcm-013",
      "kind": "operational",
      "materials": [
        "AR aging report by patient",
        "notice templates (30/60/90 day)",
        "collections agency agreement",
        "credit-reporting/consumer-protection notice language"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Run the AR aging report and sort accounts into the 30, 60, and 90-day past-due buckets with no active payment arrangement.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Identify accounts crossing 30, 60, and 90 days past due"
        },
        {
          "detail": "Which notice stage does this account need?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "n30",
              "label": "30-day: first friendly reminder"
            },
            {
              "goto": "s5",
              "id": "n60",
              "label": "60-day: firmer notice, offer payment plan"
            },
            {
              "goto": "s6",
              "id": "n90",
              "label": "90-day: final notice before escalation"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "Which notice stage does this account need?"
        },
        {
          "detail": "Send a friendly reminder notice restating the balance and inviting the patient to call about a payment plan.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Send the 30-day reminder"
        },
        {
          "detail": "Escalation cycle complete for this account",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalation cycle complete for this account"
        },
        {
          "detail": "Send a firmer notice that explicitly offers a payment plan and states what happens if the balance remains unresolved.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Send the 60-day notice with a payment-plan offer"
        },
        {
          "detail": "Send a final written notice stating the balance, the date, and that the account will be considered for outside collections referral if unresolved by a stated deadline.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Send the 90-day final notice"
        },
        {
          "detail": "Hold the account for the deadline stated in the 90-day notice (commonly 2 weeks) before any referral decision.",
          "id": "s7",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1209600,
          "title": "Wait through the final-notice response window"
        },
        {
          "detail": "Did the patient respond to the final notice?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "arranged",
              "label": "Payment arrangement made"
            },
            {
              "goto": "s10",
              "id": "no-response",
              "label": "No response by the deadline"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the patient respond to the final notice?"
        },
        {
          "detail": "Notice dates sent, owner's decision, agency referral date if applicable, and any arrangement terms, on the account.\n\nRecord: Notice dates sent, owner's decision, agency referral date if applicable, and any arrangement terms, on the account.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Log the escalation decision and outcome"
        },
        {
          "detail": "The practice owner reviews the account history and notice sequence and personally approves referral to an outside collections agency; no account is referred without this sign-off.\n\nWhy: An outside agency referral affects the patient's credit and the practice's relationship with them — this is a business decision the owner makes, never an automatic escalation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner approval required before any agency referral.",
            "role": "practice owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner approval required before any agency referral",
          "why": "An outside agency referral affects the patient's credit and the practice's relationship with them — this is a business decision the owner makes, never an automatic escalation."
        },
        {
          "detail": "Owner's decision on the account",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "refer",
              "label": "Approve agency referral"
            },
            {
              "goto": "s3",
              "id": "hold",
              "label": "Hold — give more time or negotiate directly"
            },
            {
              "goto": "s13",
              "id": "writeoff",
              "label": "Write off the balance"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Owner's decision on the account"
        },
        {
          "detail": "Submit the account package to the agreed collections agency per the agency agreement, including the notice history proving due diligence.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Refer the account to the collections agency"
        },
        {
          "detail": "Route accounts the owner decides to write off to protocol rcm-017 (write-off and adjustment approval) rather than closing them here.",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "Hand off to the write-off protocol"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Past-due account escalation (30/60/90 days, notice sequence, agency referral) — A balance passes 90 days with no arrangement — the owner approves any agency referral.",
      "title": "Past-due account escalation (30/60/90 days, notice sequence, agency referral)",
      "trigger": "A balance passes 90 days with no arrangement — the owner approves any agency referral",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z — disclosure requirements for a practice's own installment payment plans (no finance charge = generally exempt, but disclosure practice still tracked)",
          "source": "Truth in Lending Act / Regulation Z — disclosure requirements for a practice's own installment payment plans (no finance charge = generally exempt, but disclosure practice still tracked)",
          "url": "https://www.consumerfinance.gov/rules-policy/regulations/1026/"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rcm-014",
      "kind": "operational",
      "materials": [
        "payment processor decline report",
        "card-on-file update form",
        "payment plan agreement on file"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull the decline reason (insufficient funds, expired card, closed account, etc.) from the processor report for the account.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Identify the failed installment on the decline report"
        },
        {
          "detail": "Reach out by the patient's preferred contact method to let them know the installment failed and why, without accusatory language.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Contact the patient about the decline"
        },
        {
          "detail": "Can the patient update payment info now?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "update",
              "label": "Yes — patient updates card/account on file"
            },
            {
              "goto": "s8",
              "id": "unreachable",
              "label": "No response after first attempt"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Can the patient update payment info now?"
        },
        {
          "detail": "Update the payment method on file and reprocess the missed installment amount.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Update the card on file and reprocess"
        },
        {
          "detail": "Did the reprocessed or retried payment succeed?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "success",
              "label": "Payment succeeded"
            },
            {
              "goto": "s9",
              "id": "fail-again",
              "label": "Failed again or still unreachable"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "billing",
          "title": "Did the reprocessed or retried payment succeed?"
        },
        {
          "detail": "Decline date and reason, contact attempts made, whether payment was recovered, and current plan status on the account.\n\nRecord: Decline date and reason, contact attempts made, whether payment was recovered, and current plan status on the account.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Log the decline and outcome"
        },
        {
          "detail": "Installment issue resolved or escalated",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Installment issue resolved or escalated"
        },
        {
          "detail": "Follow the practice's retry sequence (a second attempt by a different channel, typically within 2-3 business days) before escalating.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Retry contact per the retry sequence"
        },
        {
          "detail": "After the retry sequence is exhausted, move the remaining balance to the regular statement cycle and flag the plan as broken.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Escalate a repeatedly failing plan"
        },
        {
          "detail": "Route the remaining balance into protocol rcm-011 (statement cycle) and, if it continues to age, protocol rcm-013 (collections escalation).",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Hand off to the statement or collections track"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Payment plan installment missed or card-on-file declined — A scheduled installment fails.",
      "title": "Payment plan installment missed or card-on-file declined",
      "trigger": "A scheduled installment fails",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "statute",
          "label": "Uniform Commercial Code Article 3 (negotiable instruments) — state adoption governs returned-check remedies and fees",
          "source": "Uniform Commercial Code Article 3 (negotiable instruments) — state adoption governs returned-check remedies and fees"
        },
        {
          "kind": "generic",
          "label": "Card network chargeback and dispute rules — merchant evidence and response-window requirements",
          "source": "Card network chargeback and dispute rules — merchant evidence and response-window requirements"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rcm-015",
      "kind": "operational",
      "materials": [
        "bank NSF/return notice or processor chargeback notice",
        "original receipt/signed authorization",
        "account ledger",
        "chargeback response evidence packet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record the amount, date of the original payment, and the reason given by the bank or processor as soon as the notice arrives.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Log the returned check or chargeback notice"
        },
        {
          "detail": "Is this a returned check (NSF) or a card chargeback?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "check",
              "label": "Returned check"
            },
            {
              "goto": "s8",
              "id": "chargeback",
              "label": "Card chargeback"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "Is this a returned check (NSF) or a card chargeback?"
        },
        {
          "detail": "Reverse the check payment in the ledger, reinstate the balance it had covered, and add any allowable returned-check fee.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Reverse the original payment and reinstate the balance"
        },
        {
          "detail": "Notify the patient of the return, the reinstated balance, and the fee, and request an alternate payment method (cash, card, or certified funds).",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the patient about the returned check"
        },
        {
          "detail": "Route any resulting balance into protocol rcm-011 (statement cycle) if the patient has not already paid an alternate way.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Hand off any unresolved balance to the statement cycle"
        },
        {
          "detail": "Notice date, amount, reason, response submitted, outcome, and resulting balance on the account.\n\nRecord: Notice date, amount, reason, response submitted, outcome, and resulting balance on the account.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Document the return or chargeback and its resolution"
        },
        {
          "detail": "Returned item / chargeback closed",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Returned item / chargeback closed"
        },
        {
          "detail": "Assemble the signed authorization or receipt, proof of service delivered, and any communication showing the charge was authorized.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Gather chargeback evidence"
        },
        {
          "detail": "The office manager reviews the evidence packet and the response wording before it is submitted to the processor within the network's response window.\n\nWhy: A chargeback response is a formal representation to the card network — it goes out reviewed, not as the first draft of whoever assembled it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor review of the chargeback response before it is submitted.",
            "role": "office manager",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor review of the chargeback response before it is submitted",
          "why": "A chargeback response is a formal representation to the card network — it goes out reviewed, not as the first draft of whoever assembled it."
        },
        {
          "detail": "Submit the reviewed evidence packet to the card processor within the stated response deadline.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Submit the chargeback response"
        },
        {
          "detail": "Hold the account pending the card network's decision, typically within about 30 days.",
          "id": "s11",
          "kind": "timer",
          "role": "billing",
          "timer_seconds": 2592000,
          "title": "Wait for the processor's determination"
        },
        {
          "detail": "Chargeback outcome",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "won",
              "label": "Won — funds restored"
            },
            {
              "goto": "s13",
              "id": "lost",
              "label": "Lost — funds remain reversed"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "billing",
          "title": "Chargeback outcome"
        },
        {
          "detail": "Reinstate the balance on the patient account and pursue it through the normal statement/collections path.",
          "id": "s13",
          "kind": "step",
          "role": "billing",
          "title": "Reinstate the balance after a lost chargeback"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Returned check or card chargeback — The bank or card processor notifies a returned item or a disputed charge.",
      "title": "Returned check or card chargeback",
      "trigger": "The bank or card processor notifies a returned item or a disputed charge",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "statute",
          "label": "42 U.S.C. §1320a-7k(d) — 60-day overpayment return rule for federal health-care program overpayments (Medicaid dental where applicable)",
          "source": "42 U.S.C. §1320a-7k(d) — 60-day overpayment return rule for federal health-care program overpayments (Medicaid dental where applicable)",
          "url": "https://www.govinfo.gov/content/pkg/USCODE-2011-title42/pdf/USCODE-2011-title42-chap7-subchapXI-partA-sec1320a-7k.pdf"
        },
        {
          "kind": "statute",
          "label": "State unclaimed-property (escheatment) statutes — outstanding, unrefundable patient credit balances after diligent search",
          "source": "State unclaimed-property (escheatment) statutes — outstanding, unrefundable patient credit balances after diligent search"
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 30,
      "frequency": "monthly",
      "id": "rcm-016",
      "kind": "operational",
      "materials": [
        "credit-balance report",
        "account ledger and payment history",
        "refund request form",
        "state unclaimed-property (escheatment) reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pull every account showing a negative (credit) balance as of month-end, or as posting creates one.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Run the credit-balance report"
        },
        {
          "detail": "Trace each credit to its cause: patient overpayment, insurance overpayment, duplicate payment posting, or a posting error.\n\nWhy: The refund recipient and the applicable deadline (e.g. the federal 60-day rule for a payer overpayment) depend on who actually overpaid.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Determine the source of each credit",
          "why": "The refund recipient and the applicable deadline (e.g. the federal 60-day rule for a payer overpayment) depend on who actually overpaid."
        },
        {
          "detail": "Who is owed the refund?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "patient",
              "label": "Patient overpaid"
            },
            {
              "goto": "s10",
              "id": "payer",
              "label": "Insurance/payer overpaid"
            },
            {
              "goto": "s11",
              "id": "error",
              "label": "Posting error, not a true overpayment"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Who is owed the refund?"
        },
        {
          "detail": "Confirm no other balance on the account should absorb the credit first, then prepare a refund request for the confirmed overpayment amount.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Prepare the patient refund request"
        },
        {
          "detail": "The office manager reviews the account history and confirms the refund amount and recipient before any check or card reversal is issued.\n\nWhy: A refund is money leaving the practice — it is approved by someone other than the person who identified the credit, the same two-person discipline as the daily deposit close.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor approval before any refund is issued.",
            "role": "office manager",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor approval before any refund is issued",
          "why": "A refund is money leaving the practice — it is approved by someone other than the person who identified the credit, the same two-person discipline as the daily deposit close."
        },
        {
          "detail": "Issue the refund by the approved method (check or card reversal) and record the transaction on the account.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Issue the refund"
        },
        {
          "detail": "Was the refund deliverable (patient reachable, address current)?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "delivered",
              "label": "Refund delivered/cashed"
            },
            {
              "goto": "s12",
              "id": "undeliverable",
              "label": "Returned or patient unreachable"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "billing",
          "title": "Was the refund deliverable (patient reachable, address current)?"
        },
        {
          "detail": "Credit source, amount, recipient, approval by whom, refund method and date, or escheatment filing if applicable.\n\nRecord: Credit source, amount, recipient, approval by whom, refund method and date, or escheatment filing if applicable.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Document the credit balance and its resolution"
        },
        {
          "detail": "Credit balance resolved",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Credit balance resolved"
        },
        {
          "detail": "Confirm the payer's preferred recoupment method (refund check vs. future claim offset) and prepare the request within the payer's or the federal 60-day overpayment-return window where it applies.",
          "id": "s10",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Prepare the payer refund or offset request"
        },
        {
          "detail": "Fix the misposted entry so the ledger reflects the true balance; no refund is issued for a correction that was never real money received.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Correct the posting error"
        },
        {
          "detail": "Make a documented good-faith attempt to locate the patient; if unsuccessful after the practice's policy period, follow the state's unclaimed-property (escheatment) process rather than absorbing the credit.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Attempt due diligence before escheatment"
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Credit balance identification and patient or payer refund — An overpayment or credit balance is found on an account at month-end or after posting — refunded within policy.",
      "title": "Credit balance identification and patient or payer refund",
      "trigger": "An overpayment or credit balance is found on an account at month-end or after posting — refunded within policy",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "generic",
          "label": "Generic internal-control principle: no single employee both proposes and approves a non-contractual write-off — segregation of duties, described in words for this class (no single public citation) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic internal-control principle: no single employee both proposes and approves a non-contractual write-off — segregation of duties, described in words for this class (no single public citation)"
          },
          "source": "Generic internal-control principle: no single employee both proposes and approves a non-contractual write-off — segregation of duties, described in words for this class (no single public citation) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rcm-017",
      "kind": "operational",
      "materials": [
        "practice management software ledger",
        "adjustment-code list",
        "written adjustment policy with dollar threshold",
        "audit log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note the account, the dollar amount, and the reason: courtesy discount, financial-hardship reduction, professional courtesy, billing-error correction, or bad-debt write-off. Distinguish this from a contractual write-off, which is the difference between billed charge and a payer's contracted allowed amount and does not need this approval path.\n\nWhy: Contractual write-offs are a mechanical consequence of the fee schedule; non-contractual adjustments give away practice revenue by discretion and need a documented reason before anyone signs off on them.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Identify the proposed adjustment and why it is non-contractual",
          "why": "Contractual write-offs are a mechanical consequence of the fee schedule; non-contractual adjustments give away practice revenue by discretion and need a documented reason before anyone signs off on them."
        },
        {
          "detail": "Check: is this reason on the approved adjustment-reason list; is the amount consistent with the policy's guidance for that reason; has this patient received a similar adjustment before (repeat courtesy discounts can mask a collections problem); is there a note in the account already explaining the circumstance.\n\nWhy: A written, repeatable checklist keeps discretionary adjustments consistent across staff and over time, rather than depending on whoever is at the desk that day.\n\nRecord: Adjustment reason code, amount, and account note in the ledger",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Confirm the adjustment against the practice's written policy",
          "why": "A written, repeatable checklist keeps discretionary adjustments consistent across staff and over time, rather than depending on whoever is at the desk that day."
        },
        {
          "detail": "The practice sets a dollar threshold in its written policy (a method-editable field); amounts under it route to the office's routine approval path, amounts at or over it require the practice owner.\n\nWhy: A flat threshold lets small, routine courtesy adjustments move quickly while reserving owner attention for amounts that materially affect revenue.",
          "forks": [
            {
              "advised": false,
              "goto": "s9",
              "id": "under-threshold",
              "label": "Under the practice's threshold"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "at-or-over-threshold",
              "label": "At or over the practice's threshold"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "billing",
          "title": "Does the adjustment amount fall under or at/over the practice's sign-off threshold?",
          "why": "A flat threshold lets small, routine courtesy adjustments move quickly while reserving owner attention for amounts that materially affect revenue."
        },
        {
          "detail": "The owner (or the practice's designated approval role in a multi-owner practice — method-editable) reviews the account, reason code, and amount, and approves or declines. Nothing is posted until this sign-off is recorded.\n\nWhy: Segregation of duties between the person who proposes a discretionary write-off and the person who approves it is the control that prevents both errors and misuse of practice revenue.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews and signs off before the adjustment posts.",
            "role": "practice-owner or designated approval role",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews and signs off before the adjustment posts",
          "why": "Segregation of duties between the person who proposes a discretionary write-off and the person who approves it is the control that prevents both errors and misuse of practice revenue."
        },
        {
          "detail": "Enter the adjustment in the practice management software linked to the approval record — approver name/role, date, reason code, amount.\n\nWhy: Linking every posted adjustment to its approval record is what makes the audit trail reconstructable later.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Post the approved adjustment to the ledger with the approval reference",
          "why": "Linking every posted adjustment to its approval record is what makes the audit trail reconstructable later."
        },
        {
          "detail": "Write account identifier, amount, reason code, approver, and date to the audit log (a separate, append-only record from the ledger entry itself).\n\nWhy: An audit log kept separately from the editable ledger cannot be quietly altered after the fact if a question comes up later.\n\nRecord: Audit log entry: account, amount, reason, approver, date",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Record the adjustment in the audit log",
          "why": "An audit log kept separately from the editable ledger cannot be quietly altered after the fact if a question comes up later."
        },
        {
          "detail": "At month-end, provide the office manager with the full list of adjustments posted that month, reason codes, and totals for reconciliation against the month-end close protocol.\n\nWhy: Aggregating adjustments monthly lets the practice see the pattern (which reason codes, which staff, which trend) rather than only ever seeing one adjustment at a time.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Hand the month's adjustment log to the office manager for the month-end audit",
          "why": "Aggregating adjustments monthly lets the practice see the pattern (which reason codes, which staff, which trend) rather than only ever seeing one adjustment at a time."
        },
        {
          "detail": "Adjustment cycle complete",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Adjustment cycle complete"
        },
        {
          "detail": "Enter the adjustment as pending in the practice management software and flag it for the next scheduled batch of routine sign-offs rather than posting it unreviewed.\n\nWhy: Even small adjustments get a second set of eyes before they leave the pending queue, so nothing posts on one person's say-so.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Route to the office's routine sign-off path for small adjustments",
          "why": "Even small adjustments get a second set of eyes before they leave the pending queue, so nothing posts on one person's say-so."
        },
        {
          "detail": "The office manager reviews the account, reason code, and amount for adjustments under the practice's dollar threshold and approves or declines — a lighter-weight review than owner sign-off, reserved for amounts under the threshold.\n\nWhy: Small, routine courtesy adjustments move quickly through a manager-level review, reserving owner attention for amounts that materially affect revenue.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager reviews and signs off on under-threshold adjustments.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager reviews and signs off on under-threshold adjustments",
          "why": "Small, routine courtesy adjustments move quickly through a manager-level review, reserving owner attention for amounts that materially affect revenue."
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Write-off and adjustment approval with audit trail — Any non-contractual adjustment is proposed.",
      "title": "Write-off and adjustment approval with audit trail",
      "trigger": "Any non-contractual adjustment is proposed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "source": "False Claims Act 31 U.S.C. §3729–3733; federal health-program overpayment return (60-day rule, 42 U.S.C. §1320a-7k(d))",
          "url": "https://www.justice.gov/civil/false-claims-act"
        },
        {
          "kind": "generic",
          "label": "Generic month-end close discipline (production/collections/AR/adjustments reconciled and locked before the next period opens) — a standard small-business accounting practice, described in words for this class — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic month-end close discipline (production/collections/AR/adjustments reconciled and locked before the next period opens) — a standard small-business accounting practice, described in words for this class"
          },
          "source": "Generic month-end close discipline (production/collections/AR/adjustments reconciled and locked before the next period opens) — a standard small-business accounting practice, described in words for this class — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 120,
      "frequency": "monthly",
      "id": "rcm-018",
      "kind": "operational",
      "materials": [
        "practice management software month-end reports",
        "bank deposit records",
        "adjustment audit log",
        "prior month's close package for comparison",
        "AR aging report"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Production report, collections report, AR aging report, adjustments/write-offs report, deposit slips for the month, and the prior month's signed-off close package for comparison.\n\nWhy: Month-end close depends on having every source report in hand before reconciliation starts, so nothing is reconstructed from memory partway through.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Pull the month's core financial reports",
          "why": "Month-end close depends on having every source report in hand before reconciliation starts, so nothing is reconstructed from memory partway through."
        },
        {
          "detail": "Match each day's recorded deposit (from the daily deposit and day-sheet close protocol) against the bank statement for the month; flag any deposit that does not match by date or amount.\n\nWhy: Deposits that were logged but never actually reached the bank — or vice versa — are the most common source of month-end discrepancy and the easiest to miss if not checked line by line.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Reconcile daily deposits to the bank statement",
          "why": "Deposits that were logged but never actually reached the bank — or vice versa — are the most common source of month-end discrepancy and the easiest to miss if not checked line by line."
        },
        {
          "detail": "Confirm the aging report total matches the sum of outstanding insurance claims plus outstanding patient balances tracked elsewhere in the system; investigate any variance.\n\nWhy: An AR total that does not tie back to its own components usually means a posting error somewhere in the month, and it compounds if carried unreconciled into the next month.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Reconcile the AR aging report against outstanding claims and patient balances",
          "why": "An AR total that does not tie back to its own components usually means a posting error somewhere in the month, and it compounds if carried unreconciled into the next month."
        },
        {
          "detail": "Pull every adjustment posted this month (from the write-off and adjustment approval protocol) and confirm each has a matching approval reference; flag any adjustment posted without one.\n\nWhy: Month-end is the checkpoint that catches a control failure in the write-off approval process before it repeats for another month.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the month's adjustment and write-off audit log",
          "why": "Month-end is the checkpoint that catches a control failure in the write-off approval process before it repeats for another month."
        },
        {
          "detail": "Compare this month's production, collection rate, and AR days against the prior month and the practice's typical range.\n\nWhy: Most months close routinely; a variance beyond the practice's normal range is the signal that something needs investigation before the books are locked.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "within-normal",
              "label": "All reconciliations tie out within normal variance"
            },
            {
              "advised": false,
              "goto": "s10",
              "id": "unexplained-gap",
              "label": "An unexplained gap or unmatched adjustment remains"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are all reconciliations within the practice's normal variance, or is there an unexplained gap?",
          "why": "Most months close routinely; a variance beyond the practice's normal range is the signal that something needs investigation before the books are locked."
        },
        {
          "detail": "Compile the reconciled reports, the resolved variance notes (if any), and summary figures (production, collections, AR days, adjustments total) into the month's close package.\n\nWhy: A single assembled package is what makes the month's financial position reviewable by the owner and comparable to prior months.\n\nRecord: Month-end close package: reconciled reports, variance notes, summary figures",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Assemble the signed close package",
          "why": "A single assembled package is what makes the month's financial position reviewable by the owner and comparable to prior months."
        },
        {
          "detail": "The owner reviews the summary figures and any variance notes and signs off that the month is closed. A practice with a designated office-manager-only close (method-editable) records the office manager's own sign-off instead.\n\nWhy: A second reviewer on the finalized numbers, before the books lock, catches what the person who assembled them may not see in their own work.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews and signs off on the close.",
            "role": "practice-owner (or office manager where the practice has designated manager-only close)",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews and signs off on the close",
          "why": "A second reviewer on the finalized numbers, before the books lock, catches what the person who assembled them may not see in their own work."
        },
        {
          "detail": "Set the period to closed/locked so no further postings land in the closed month without an explicit reopen.\n\nWhy: Locking the period prevents a later correction from silently changing numbers that were already reviewed and signed off.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Lock the closed period in the practice management software",
          "why": "Locking the period prevents a later correction from silently changing numbers that were already reviewed and signed off."
        },
        {
          "detail": "Month-end close complete",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Month-end close complete"
        },
        {
          "detail": "Trace the specific deposit, claim, or adjustment back to its source entry; correct a posting error, or document the explanation if it is legitimate (e.g., a late-arriving deposit).\n\nWhy: Closing the month with an unexplained gap just moves the problem into next month, where it is harder to trace back to its cause.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Investigate the specific unmatched item before proceeding",
          "why": "Closing the month with an unexplained gap just moves the problem into next month, where it is harder to trace back to its cause."
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Month-end close (AR reconciliation, production, adjustments audit) — The last business day of the month or the first of the next.",
      "title": "Month-end close (AR reconciliation, production, adjustments audit)",
      "trigger": "The last business day of the month or the first of the next",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "regulation",
          "label": "IRS information-return requirements for payments to independent contractors and vendors (Form 1099 series)",
          "source": "IRS information-return requirements for payments to independent contractors and vendors (Form 1099 series)",
          "url": "https://www.irs.gov/businesses/small-businesses-self-employed/am-i-required-to-file-a-form-1099-or-other-information-return"
        },
        {
          "kind": "generic",
          "label": "Generic year-end close/handoff discipline (twelve reconciled months rolled into one annual package for the practice's tax preparer) — described in words for this class — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic year-end close/handoff discipline (twelve reconciled months rolled into one annual package for the practice's tax preparer) — described in words for this class"
          },
          "source": "Generic year-end close/handoff discipline (twelve reconciled months rolled into one annual package for the practice's tax preparer) — described in words for this class — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 180,
      "frequency": "annual",
      "id": "rcm-019",
      "kind": "operational",
      "materials": [
        "twelve signed month-end close packages",
        "annual production and collections summary",
        "vendor payment and 1099 records",
        "refund log",
        "prior-year package for comparison",
        "accountant's request checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull each month's package from the month-end close protocol; note any month missing a package or a sign-off and complete it before proceeding.\n\nWhy: A year-end package built on top of an unclosed month inherits that month's unresolved variance into the annual figures.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm all twelve months have a signed close package on file",
          "why": "A year-end package built on top of an unclosed month inherits that month's unresolved variance into the annual figures."
        },
        {
          "detail": "Check the twelve close packages against the calendar year.\n\nWhy: Completing a missing month now is far cheaper than the accountant flagging it later, or the practice filing on incomplete numbers.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "all-complete",
              "label": "All twelve months complete"
            },
            {
              "advised": false,
              "goto": "s9",
              "id": "gap-found",
              "label": "One or more months missing or unsigned"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are all twelve months complete and signed off?",
          "why": "Completing a missing month now is far cheaper than the accountant flagging it later, or the practice filing on incomplete numbers."
        },
        {
          "detail": "Roll the twelve monthly summaries into annual totals: production, collections, AR aging at year-end, total adjustments/write-offs by reason code.\n\nWhy: The accountant needs the year as one reconciled figure set, not twelve separate packages to re-add themselves.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the annual production, collections and adjustments summary",
          "why": "The accountant needs the year as one reconciled figure set, not twelve separate packages to re-add themselves."
        },
        {
          "detail": "List every independent-contractor or vendor payment for the year; confirm a current W-9 is on file for each; flag any vendor at or above the federal reporting threshold without one.\n\nWhy: Missing vendor tax documentation found at year-end, rather than in January when 1099s are due, is a common and avoidable year-end scramble.\n\nRecord: Vendor payment list with W-9 status flagged",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Assemble vendor payment records and check 1099 status",
          "why": "Missing vendor tax documentation found at year-end, rather than in January when 1099s are due, is a common and avoidable year-end scramble."
        },
        {
          "detail": "List every patient and payer refund issued during the year with date, amount, and reason, pulled from the refund process referenced in this class.\n\nWhy: Refunds affect net collections and need to be visible to the accountant separately from routine adjustments.\n\nRecord: Annual refund log: date, amount, reason, payee",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Assemble the year's refund log",
          "why": "Refunds affect net collections and need to be visible to the accountant separately from routine adjustments."
        },
        {
          "detail": "The owner reviews the annual summary, vendor/1099 flags, and refund log for anything that looks wrong or needs their own knowledge to explain, and approves sending it.\n\nWhy: The owner often holds context (a one-time expense, an unusual refund) that the office staff assembling the package would not otherwise be able to explain to the accountant.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews the assembled package before it goes to the accountant.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews the assembled package before it goes to the accountant",
          "why": "The owner often holds context (a one-time expense, an unusual refund) that the office staff assembling the package would not otherwise be able to explain to the accountant."
        },
        {
          "detail": "Send the annual summary, twelve month-end close packages, vendor/1099 records, and refund log to the accountant through the practice's agreed secure channel, against the accountant's own checklist if one exists.\n\nWhy: A named handoff with a receipt (confirmation the accountant has it) closes the loop instead of leaving the package to be assumed sent.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Deliver the year-end package to the practice's accountant",
          "why": "A named handoff with a receipt (confirmation the accountant has it) closes the loop instead of leaving the package to be assumed sent."
        },
        {
          "detail": "Year-end financial package delivered",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Year-end financial package delivered"
        },
        {
          "detail": "Run the month-end close protocol retroactively for the flagged month, including owner sign-off, before folding it into the annual package.\n\nWhy: Backfilling a close after the fact still needs the same reconciliation and sign-off discipline as a close done on time.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Complete the missing month's close before continuing",
          "why": "Backfilling a close after the fact still needs the same reconciliation and sign-off discipline as a close done on time."
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Year-end financial package for the accountant — December/January — reports, adjustments, refunds and vendor payments assembled for the accountant.",
      "title": "Year-end financial package for the accountant",
      "trigger": "December/January — reports, adjustments, refunds and vendor payments assembled for the accountant",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "generic",
          "label": "Generic network-participation principle: a provider under a PPO contract may collect only the contracted allowed amount (patient responsibility plus plan payment) and must write off the balance above it — the contract itself, not a public statute, sets the specific number for a given plan; no single public citation for the mechanism — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic network-participation principle: a provider under a PPO contract may collect only the contracted allowed amount (patient responsibility plus plan payment) and must write off the balance above it — the contract itself, not a public statute, sets the specific number for a given plan; no single public citation for the mechanism"
          },
          "source": "Generic network-participation principle: a provider under a PPO contract may collect only the contracted allowed amount (patient responsibility plus plan payment) and must write off the balance above it — the contract itself, not a public statute, sets the specific number for a given plan; no single public citation for the mechanism — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "rcm-020",
      "kind": "operational",
      "materials": [
        "current PPO fee schedule for the plan",
        "the signed provider participation contract",
        "practice management software fee-schedule table",
        "explanation of benefits from the plan"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "insurance-coordinator",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check the patient's plan against the practice's current list of contracted PPO plans and confirm the provider participation status has not lapsed.\n\nWhy: Applying an out-of-network fee schedule to an in-network patient, or the reverse, is the root cause of most balance-billing errors.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Confirm whether the patient's plan is in-network (PPO-contracted) for the practice",
          "why": "Applying an out-of-network fee schedule to an in-network patient, or the reverse, is the root cause of most balance-billing errors."
        },
        {
          "detail": "Compare the fee-schedule table in the practice management software against the most recent fee schedule the plan has sent for this contract year.\n\nWhy: Plans update contracted fees periodically; a stale table charges the wrong amount even when everyone follows the process correctly.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "current",
              "label": "Fee schedule is current"
            },
            {
              "advised": false,
              "goto": "s8",
              "id": "stale",
              "label": "Fee schedule is missing or outdated"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Is the current fee schedule for this plan loaded and up to date in the software?",
          "why": "Plans update contracted fees periodically; a stale table charges the wrong amount even when everyone follows the process correctly."
        },
        {
          "detail": "Calculate the patient's portion as the contracted allowed amount minus the plan's payment (co-insurance/deductible per the plan), never the practice's full list price for a contracted procedure.\n\nWhy: The provider participation contract requires charging contracted patients only the allowed amount, not the practice's standard fee — collecting more is a balance-billing violation of the contract.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Bill the patient only the contracted patient responsibility",
          "why": "The provider participation contract requires charging contracted patients only the allowed amount, not the practice's standard fee — collecting more is a balance-billing violation of the contract."
        },
        {
          "detail": "Post the contractual write-off (billed charge minus allowed amount) as a contractual adjustment — this is distinct from the discretionary write-off and adjustment approval protocol and does not need owner sign-off, since it is a mechanical result of the contract.\n\nWhy: Separating contractual write-offs (required by the contract) from discretionary ones (a business decision) keeps the audit trail meaningful for both.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Write off the difference between billed charge and the contracted allowed amount",
          "why": "Separating contractual write-offs (required by the contract) from discretionary ones (a business decision) keeps the audit trail meaningful for both."
        },
        {
          "detail": "On the practice's set cadence (method-editable), sample a set of recently billed contracted claims and verify each was billed and written off at the correct contracted amount.\n\nWhy: A spot-check catches a fee-schedule table error or a one-off mistake before it repeats across many patients on the same plan.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Run the practice's periodic spot-check of contracted claims",
          "why": "A spot-check catches a fee-schedule table error or a one-off mistake before it repeats across many patients on the same plan."
        },
        {
          "detail": "Compare each sampled claim's billed patient portion against the contracted fee schedule.\n\nWhy: A found overcharge needs to be corrected and, where a patient already paid it, refunded — silence would leave the balance-billing violation standing.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "clean",
              "label": "No overcharge found"
            },
            {
              "goto": "s9",
              "id": "overcharge-found",
              "label": "A patient was billed above the contracted amount"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "billing",
          "title": "Did the spot-check find any patient billed above the contracted amount?",
          "why": "A found overcharge needs to be corrected and, where a patient already paid it, refunded — silence would leave the balance-billing violation standing."
        },
        {
          "detail": "PPO compliance check complete",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "PPO compliance check complete"
        },
        {
          "detail": "Load the plan's current fee schedule into the practice management software table for that plan, dated, before the patient's charges are calculated.\n\nWhy: Fixing the table before billing prevents needing a balance-billing correction and refund afterward.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Update the fee-schedule table before billing",
          "why": "Fixing the table before billing prevents needing a balance-billing correction and refund afterward."
        },
        {
          "detail": "The owner reviews how many patients were affected, whether it is a one-off error or a systemic fee-schedule problem, and approves the correction and refund plan.\n\nWhy: A balance-billing overcharge is a contract-compliance issue, not just a bookkeeping fix — the owner needs to know if the contract or the practice's process needs to change, not just this one account.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews the overcharge before the correction and any refund goes out.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews the overcharge before the correction and any refund goes out",
          "why": "A balance-billing overcharge is a contract-compliance issue, not just a bookkeeping fix — the owner needs to know if the contract or the practice's process needs to change, not just this one account."
        },
        {
          "detail": "Adjust the account to the correct contracted amount and issue a refund to the patient for any amount collected above it, following the practice's refund process.\n\nWhy: The correction is not complete until the patient has actually been made whole, not just the ledger.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Correct the account and refund any overpayment",
          "why": "The correction is not complete until the patient has actually been made whole, not just the ledger."
        },
        {
          "detail": "Record the plan, the affected claim(s), the cause (stale fee schedule, manual error, other), the correction made, and the refund amount and date.\n\nWhy: A logged pattern of findings is what tells the practice whether one plan's fee schedule needs closer attention going forward.\n\nRecord: Compliance finding log: plan, claim, cause, correction, refund",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Log the finding and correction for the compliance record",
          "why": "A logged pattern of findings is what tells the practice whether one plan's fee schedule needs closer attention going forward."
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "PPO contract compliance — contracted fees, write-offs and balance-billing limits — A contracted patient is charged, or a new fee schedule is loaded.",
      "title": "PPO contract compliance — contracted fees, write-offs and balance-billing limits",
      "trigger": "A contracted patient is charged, or a new fee schedule is loaded",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "source": "HIPAA transaction standards 45 CFR Part 162 — 837D claim, 835 remittance",
          "url": "https://www.ecfr.gov/current/title-45/part-162"
        },
        {
          "kind": "statute",
          "label": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications",
          "source": "Fair Debt Collection Practices Act 15 U.S.C. §1692 — applies once an account is placed with an outside collector, not to a practice's own first-party billing; California Rosenthal Act Civ. Code §1788 (reaches original creditors collecting their own debts) and state prompt-pay statutes apply directly to the practice's own billing communications"
        },
        {
          "kind": "generic",
          "label": "Generic principle: state workers'-compensation systems and auto no-fault/med-pay coverage each set their own dental fee schedule, billing rules, and timely-filing rules that differ by state — described in words for this class; the practice's own state's workers'-compensation dental fee schedule is the specific public source to consult when this protocol fires — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic principle: state workers'-compensation systems and auto no-fault/med-pay coverage each set their own dental fee schedule, billing rules, and timely-filing rules that differ by state — described in words for this class; the practice's own state's workers'-compensation dental fee schedule is the specific public source to consult when this protocol fires"
          },
          "source": "Generic principle: state workers'-compensation systems and auto no-fault/med-pay coverage each set their own dental fee schedule, billing rules, and timely-filing rules that differ by state — described in words for this class; the practice's own state's workers'-compensation dental fee schedule is the specific public source to consult when this protocol fires — Practice policy — no published authority governs this step."
        }
      ],
      "class": "revenue-cycle-payer-compliance",
      "department": "finance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rcm-021",
      "kind": "operational",
      "materials": [
        "patient's auto/workers'-comp insurance or claim information",
        "letter of protection (if offered)",
        "state workers'-compensation dental fee schedule (if applicable)",
        "itemized treatment estimate",
        "practice's letter-of-protection acceptance policy"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "office-manager",
        "practice-owner",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Determine whether this is an auto-accident claim (often with med-pay or no-fault coverage), a workers'-compensation claim, or a general third-party liability claim (another party's negligence, often via an attorney).\n\nWhy: Each pathway has its own fee schedule, filing process, and payer, so misidentifying it at the start sends the claim down the wrong billing path.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Identify which liability pathway applies",
          "why": "Each pathway has its own fee schedule, filing process, and payer, so misidentifying it at the start sends the claim down the wrong billing path."
        },
        {
          "detail": "A letter of protection is an attorney's written promise to pay the practice from any eventual settlement, instead of the patient paying at time of service.\n\nWhy: Accepting a letter of protection means treatment is delivered before payment is certain — the practice needs a deliberate policy decision here, not a front-desk improvisation.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-lop",
              "label": "No letter of protection offered — bill the identified payer directly"
            },
            {
              "advised": false,
              "goto": "s8",
              "id": "lop-offered",
              "label": "A letter of protection has been offered"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Has the patient's attorney offered a letter of protection in lieu of payment at time of service?",
          "why": "Accepting a letter of protection means treatment is delivered before payment is certain — the practice needs a deliberate policy decision here, not a front-desk improvisation."
        },
        {
          "detail": "Submit the claim to the auto med-pay/no-fault carrier or the workers'-compensation carrier using that state's specific dental fee schedule and claim form; for a general liability claim without a letter of protection, bill the patient's own dental insurance first if coordination of benefits allows, per plan rules.\n\nWhy: State workers'-comp and auto-liability systems each run on their own fee schedule and filing rules, distinct from ordinary dental-insurance claims — using the wrong form or fee schedule is a common cause of rejection here.",
          "id": "s3",
          "kind": "step",
          "role": "billing",
          "title": "Bill the identified auto/workers'-comp payer or the liable third party",
          "why": "State workers'-comp and auto-liability systems each run on their own fee schedule and filing rules, distinct from ordinary dental-insurance claims — using the wrong form or fee schedule is a common cause of rejection here."
        },
        {
          "detail": "Track the claim or case alongside the outstanding-claims aging protocol, but flag it separately since resolution timelines for liability and workers'-comp cases run longer than routine dental claims.\n\nWhy: A third-party or letter-of-protection account can sit open far longer than a normal claim without being a sign of a process failure — it still needs regular, not urgent, follow-up.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Monitor the claim or letter-of-protection case on a periodic follow-up schedule",
          "why": "A third-party or letter-of-protection account can sit open far longer than a normal claim without being a sign of a process failure — it still needs regular, not urgent, follow-up."
        },
        {
          "detail": "The case pays in full, pays partially (settlement shortfall), or is denied/uncollectable.\n\nWhy: Each outcome routes to a different next step — full payment simply posts, but a shortfall or denial needs a decision about write-off versus continued collection.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "paid-full",
              "label": "Paid in full per the fee schedule or letter of protection"
            },
            {
              "goto": "s11",
              "id": "shortfall-or-denied",
              "label": "Partial settlement shortfall or denied"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "How did the case resolve?",
          "why": "Each outcome routes to a different next step — full payment simply posts, but a shortfall or denial needs a decision about write-off versus continued collection."
        },
        {
          "detail": "Post the payment against the treatment estimate on file and close out the third-party/letter-of-protection flag on the account.\n\nWhy: Closing the flag keeps the aging and follow-up lists accurate for the accounts still genuinely open.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Post the payment and close the account",
          "why": "Closing the flag keeps the aging and follow-up lists accurate for the accounts still genuinely open."
        },
        {
          "detail": "Third-party liability claim resolved",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Third-party liability claim resolved"
        },
        {
          "detail": "The owner reviews the letter's terms, the treatment estimate, and the practice's own policy limits on accepted letters of protection (method-editable) before deciding whether to proceed on that basis.\n\nWhy: A letter of protection carries collection risk if the case settles for less than expected or not at all — that risk decision belongs to the practice owner, not to whoever is scheduling the appointment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner approves whether to accept the letter of protection.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner approves whether to accept the letter of protection",
          "why": "A letter of protection carries collection risk if the case settles for less than expected or not at all — that risk decision belongs to the practice owner, not to whoever is scheduling the appointment."
        },
        {
          "detail": "Record the owner's decision before scheduling treatment on that basis.\n\nWhy: Treatment should not begin on a letter-of-protection basis until the approval is on record, since reversing course after treatment has been delivered is far harder.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "approved",
              "label": "Approved — proceed on the letter of protection"
            },
            {
              "advised": false,
              "goto": "s3",
              "id": "declined",
              "label": "Declined — bill the identified payer or patient directly instead"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the owner approve accepting the letter of protection?",
          "why": "Treatment should not begin on a letter-of-protection basis until the approval is on record, since reversing course after treatment has been delivered is far harder."
        },
        {
          "detail": "File the signed letter, the attorney's contact information, and the treatment estimate it covers on the patient's account.\n\nWhy: The account needs a clear record of what was promised and by whom, since resolution can take months or years.\n\nRecord: Letter of protection on file: attorney, terms, treatment estimate covered",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the letter of protection terms on the account",
          "why": "The account needs a clear record of what was promised and by whom, since resolution can take months or years."
        },
        {
          "detail": "Hand the unpaid balance to the write-off and adjustment approval protocol for the practice owner's decision on writing it off versus continued patient collection, rather than deciding unilaterally here.\n\nWhy: A liability-case shortfall is still a discretionary, non-contractual write-off from the practice's perspective and belongs on the same approval path as any other one.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Route any shortfall to the write-off and adjustment approval protocol",
          "why": "A liability-case shortfall is still a discretionary, non-contractual write-off from the practice's perspective and belongs on the same approval path as any other one."
        }
      ],
      "subclass": "claims-posting-ar-and-payer-compliance",
      "summary": "Third-party liability, auto-accident and workers'-compensation dental claim — A patient's dental injury arose from a car crash, workplace accident or another party's negligence, or an attorney offers a letter of protection.",
      "title": "Third-party liability, auto-accident and workers'-compensation dental claim",
      "trigger": "A patient's dental injury arose from a car crash, workplace accident or another party's negligence, or an attorney offers a letter of protection",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis)"
        },
        {
          "kind": "open_standard",
          "label": "ADA/FDA amalgam and composite patient-group guidance (open)",
          "source": "ADA/FDA amalgam and composite patient-group guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (materials SDS for bonding agents)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (materials SDS for bonding agents)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "rdir-001",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "rubber dam or alternative isolation",
        "sectional matrix system and wedges",
        "etch/bond materials",
        "posterior composite resin, shade-matched",
        "curing light",
        "articulating paper",
        "finishing/polishing instruments"
      ],
      "needs_ack_review": true,
      "outcomes": [
        "sensitivity_48h",
        "patient_reported_scale"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Verify the tooth number, surfaces to be restored, and target shade against the treatment plan and radiograph before anesthetic is given.\n\nWhy: Wrong-tooth and wrong-surface errors are caught cheaply before anything irreversible happens.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm tooth, surfaces and shade before starting",
          "why": "Wrong-tooth and wrong-surface errors are caught cheaply before anything irreversible happens."
        },
        {
          "detail": "Confirm a signed consent for the restorative procedure is in the chart, or complete the consent conversation now, before administering anesthetic.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent on file before treatment.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent on file before treatment"
        },
        {
          "detail": "Review the chart for allergy to the local anesthetic or vasoconstrictor being used, cardiac disease, and MAOI or other relevant drug interactions before administering anesthesia.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm anesthetic and vasoconstrictor allergy/history before injecting"
        },
        {
          "detail": "Administer local anesthetic appropriate to the tooth and confirm profound anesthesia before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Select isolation method",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "dam",
              "label": "Rubber dam isolation"
            },
            {
              "goto": "s6",
              "id": "alt",
              "label": "Alternative isolation (cotton roll, retraction cord, isolation device)"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Select isolation method"
        },
        {
          "detail": "Remove all caries with rotary or hand instruments, preserving sound tooth structure, and shape the preparation for a bonded restoration.\n\nWhy: A conservative prep preserves tooth strength; incomplete caries removal causes early failure.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Remove caries and prepare the cavity",
          "why": "A conservative prep preserves tooth strength; incomplete caries removal causes early failure."
        },
        {
          "detail": "Place a sectional matrix band and wedge to re-establish the proximal contact and contour before bonding.\n\nWhy: A poorly contoured matrix produces an open contact that traps food and causes recurrent decay.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Place matrix band and wedge",
          "why": "A poorly contoured matrix produces an open contact that traps food and causes recurrent decay."
        },
        {
          "detail": "Etch enamel and dentin per the product's timing, rinse, dry to the correct moisture level, apply bonding agent, and light-cure per the manufacturer's stated time.\n\nRecord: Bonding system used logged to the encounter",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Etch and bond per manufacturer protocol"
        },
        {
          "detail": "Place and light-cure composite in increments no thicker than about 2mm, building anatomy and contact as you go.\n\nWhy: Thick increments under-cure at the base and increase polymerization shrinkage stress, risking postoperative sensitivity.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Place composite in cured increments",
          "why": "Thick increments under-cure at the base and increase polymerization shrinkage stress, risking postoperative sensitivity."
        },
        {
          "detail": "Remove the matrix and wedge and inspect the proximal contact and margins for excess flash.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Remove matrix band and wedge"
        },
        {
          "detail": "Have the patient bite on articulating paper in maximum intercuspation and lateral excursions; adjust and polish any high spots.\n\nWhy: A high restoration causes post-op pain and can fracture under bite force before it is caught.\n\nRecord: Occlusion checked and adjusted, noted in the SOAP note",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Check and adjust occlusion",
          "why": "A high restoration causes post-op pain and can fracture under bite force before it is caught."
        },
        {
          "detail": "Contour and polish the restoration to a smooth surface and confirm floss passes cleanly through the contact.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Finish and polish the restoration"
        },
        {
          "detail": "Remove the rubber dam or alternative isolation and rinse the patient's mouth.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Remove isolation and rinse"
        },
        {
          "detail": "Explain that numbness will wear off, avoid chewing on the numb side until sensation returns, and expect possible mild sensitivity to cold for a few days.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Log tooth, surfaces, materials/shade, anesthetic used, isolation method, and occlusion check result in the SOAP note.\n\nRecord: Procedure note in the chart with materials and occlusion check",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Log the restoration to the practice's clinical metrics tracker (isolation method, occlusion check completed).\n\nRecord: Metrics entry for restoration tracking",
          "id": "s16",
          "kind": "step",
          "role": "office-manager",
          "title": "Log restoration metrics"
        },
        {
          "detail": "Restoration complete",
          "id": "s17",
          "kind": "step",
          "role": "dentist",
          "title": "Restoration complete"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Posterior composite (Class I/II) — isolation, matrix, incremental placement, occlusion — Caries or a failed restoration in a posterior tooth is planned for direct composite.",
      "title": "Posterior composite (Class I/II) — isolation, matrix, incremental placement, occlusion",
      "trigger": "Caries or a failed restoration in a posterior tooth is planned for direct composite",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis)"
        },
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims (the photographs taken in this protocol are for clinical chart documentation only; separate marketing-use consent is required before any subsequent advertising use of these images)",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims (the photographs taken in this protocol are for clinical chart documentation only; separate marketing-use consent is required before any subsequent advertising use of these images)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=651",
          "url_verified_at": "2026-09-14"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-patient",
      "id": "rdir-002",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "isolation (dam or retraction cord)",
        "shade guide",
        "layered composite kit (dentin/enamel shades)",
        "matrix strip for anterior proximal work",
        "curing light",
        "polishing discs and points"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Select the target shade against adjacent and contralateral teeth and photograph it before administering anesthetic.\n\nWhy: Teeth dehydrate and appear lighter once isolated and dried, so shade taken mid-procedure is unreliable.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Take shade and reference photo before anesthesia",
          "why": "Teeth dehydrate and appear lighter once isolated and dried, so shade taken mid-procedure is unreliable."
        },
        {
          "detail": "Confirm signed consent covering the procedure and a realistic discussion of expected esthetic outcome and limitations of direct composite.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent, including esthetic expectations.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent, including esthetic expectations"
        },
        {
          "detail": "Review the chart for allergy to the local anesthetic or vasoconstrictor being used, cardiac disease, and MAOI or other relevant drug interactions before administering anesthesia.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm anesthetic and vasoconstrictor allergy/history before injecting"
        },
        {
          "detail": "Administer local anesthetic and confirm profound anesthesia before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Place a rubber dam where feasible, or retraction cord and cotton roll isolation for cervical (Class V) lesions.\n\nWhy: Anterior bonding is highly moisture-sensitive; contamination is the leading cause of early bond failure.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the field",
          "why": "Anterior bonding is highly moisture-sensitive; contamination is the leading cause of early bond failure."
        },
        {
          "detail": "Remove caries or smooth the fracture margin, bevel enamel margins where esthetics benefit from a longer bevel.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the lesion or fracture margin"
        },
        {
          "detail": "Does the case need a proximal matrix?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "Class III/IV — place a clear matrix strip"
            },
            {
              "goto": "s8",
              "id": "no",
              "label": "Class V — no matrix needed"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the case need a proximal matrix?"
        },
        {
          "detail": "Etch, rinse, dry to correct moisture level, apply bonding agent, and light-cure per the manufacturer's stated time.\n\nRecord: Bonding system used logged to the encounter",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Etch and bond per manufacturer protocol"
        },
        {
          "detail": "Build internal dentin-shade composite first for depth and opacity, then a translucent enamel-shade layer over it, curing each increment.\n\nWhy: Single-shade composite looks flat; layering mimics natural tooth translucency and depth.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Layer dentin and enamel shades",
          "why": "Single-shade composite looks flat; layering mimics natural tooth translucency and depth."
        },
        {
          "detail": "Sculpt line angles, texture and contour to match adjacent teeth while the material is workable.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Shape and contour before final cure"
        },
        {
          "detail": "Remove the dam or retraction cord, dry, and check the restoration does not interfere in excursive movements.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Remove isolation and check occlusion"
        },
        {
          "detail": "Use a graduated polishing sequence to match the surface luster of adjacent natural teeth.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Finish and polish for shade and luster match"
        },
        {
          "detail": "Photograph the finished restoration next to the pre-op reference photo for the chart.\n\nWhy: A documented before/after supports quality review and any esthetic follow-up conversation.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Take a final comparison photo",
          "why": "A documented before/after supports quality review and any esthetic follow-up conversation."
        },
        {
          "detail": "Explain numbness will wear off, avoid biting hard foods on the treated side today, and mild sensitivity is normal for a few days.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Log tooth, surfaces, shade layering system, isolation method, and occlusion check in the SOAP note.\n\nRecord: Procedure note with shade and materials",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Restoration complete",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Restoration complete"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Anterior composite (Class III/IV/V) with shade layering — Anterior caries, fracture or a cervical lesion is planned for direct composite.",
      "title": "Anterior composite (Class III/IV/V) with shade layering",
      "trigger": "Anterior caries, fracture or a cervical lesion is planned for direct composite",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis, isolation dependency)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis, isolation dependency)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (latex allergy consideration for dam material)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (latex allergy consideration for dam material)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "rdir-003",
      "kind": "clinical",
      "materials": [
        "rubber dam sheet and frame",
        "dam clamps (assorted sizes)",
        "dam punch",
        "floss or dental tape",
        "alternative isolation devices (cotton roll holder, isolation device, retraction cord)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the chart for a documented latex allergy before selecting dam material; confirm verbally with the patient if not already noted, and do not proceed with latex isolation material until this is cleared.\n\nWhy: Standard rubber dam contains latex; an unscreened allergy can trigger a reaction mid-procedure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Screen for latex or material allergy before isolation.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "assistant",
          "title": "Screen for latex or material allergy before isolation",
          "why": "Standard rubber dam contains latex; an unscreened allergy can trigger a reaction mid-procedure."
        },
        {
          "detail": "Select isolation method for this procedure",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "dam",
              "label": "Rubber dam (non-latex if allergy noted)"
            },
            {
              "goto": "s9",
              "id": "alt",
              "label": "Alternative isolation (cotton roll, isolation device, retraction cord)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Select isolation method for this procedure"
        },
        {
          "detail": "Mark and punch holes in the dam sheet matching the tooth positions to be isolated, sized for the clamp and adjacent teeth.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Punch the dam for the teeth being treated"
        },
        {
          "detail": "Select a clamp sized to the tooth, seat it with floss ligature attached for retrieval, and confirm it does not impinge on gingival tissue.\n\nWhy: A floss ligature lets the clamp be retrieved quickly if it dislodges toward the airway.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Select and seat the clamp",
          "why": "A floss ligature lets the clamp be retrieved quickly if it dislodges toward the airway."
        },
        {
          "detail": "Stretch the dam over the frame, seat it around the clamped tooth and adjacent teeth, and invert the margins with floss for a tight seal.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Seat the dam over the frame and invert margins"
        },
        {
          "detail": "Check for saliva leakage around the dam margins before proceeding; re-seat or add a sealant material if any leakage is present.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm dry field and no leakage"
        },
        {
          "detail": "Note the isolation method used for the procedure in the encounter record.\n\nRecord: Isolation method logged to the encounter",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log isolation method used"
        },
        {
          "detail": "Field isolated, ready for procedure",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Field isolated, ready for procedure"
        },
        {
          "detail": "Place cotton rolls with a holder, an isolation device, or retraction cord as appropriate to the tooth and procedure.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Place alternative isolation"
        },
        {
          "detail": "Confirm the alternative isolation provides a field dry enough for bonding before proceeding; escalate to dam isolation if not.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm adequate moisture control"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Rubber dam placement and alternative isolation selection — Any bonded procedure or endodontic access is about to start.",
      "title": "Rubber dam placement and alternative isolation selection",
      "trigger": "Any bonded procedure or endodontic access is about to start",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "EPA 40 CFR 441 Dental Amalgam Effluent Rule",
          "source": "EPA 40 CFR 441 Dental Amalgam Effluent Rule",
          "url": "https://www.epa.gov/eg/dental-effluent-guidelines"
        },
        {
          "kind": "open_standard",
          "label": "ADA/FDA amalgam patient-group guidance (open)",
          "source": "ADA/FDA amalgam patient-group guidance (open)"
        },
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.2 (in-repo amalgam basis)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.2 (in-repo amalgam basis)"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 35,
      "frequency": "per-patient",
      "id": "rdir-004",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "isolation",
        "encapsulated amalgam capsules",
        "amalgamator",
        "amalgam carrier and condensers",
        "amalgam separator on the vacuum line",
        "carving instruments"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Screen for pregnancy or nursing status, patient age under 6, known mercury allergy, and impaired renal or neurological function; document an alternative-material discussion with the patient when any of these risk factors is present, before the consent conversation proceeds.\n\nWhy: FDA amalgam safety communication guidance flags these groups for a specific alternative-material discussion rather than amalgam by default.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Screen for amalgam risk-group factors before offering the material",
          "why": "FDA amalgam safety communication guidance flags these groups for a specific alternative-material discussion rather than amalgam by default."
        },
        {
          "detail": "Confirm the signed consent specifically discusses amalgam as the restorative material and any patient questions about it before starting.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent names amalgam as the selected material.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent names amalgam as the selected material"
        },
        {
          "detail": "Review the chart for allergy to the local anesthetic or vasoconstrictor being used, cardiac disease, and MAOI or other relevant drug interactions before administering anesthesia.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm anesthetic and vasoconstrictor allergy/history before injecting"
        },
        {
          "detail": "Administer local anesthetic and confirm profound anesthesia before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Place a rubber dam or alternative isolation appropriate to the tooth.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the field"
        },
        {
          "detail": "Remove caries and shape the preparation with mechanical retention features appropriate for amalgam (undercuts, box forms).\n\nWhy: Unlike bonded composite, amalgam relies on mechanical retention rather than adhesion.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Remove caries and prepare a retentive cavity form",
          "why": "Unlike bonded composite, amalgam relies on mechanical retention rather than adhesion."
        },
        {
          "detail": "Select the correctly sized pre-encapsulated amalgam capsule and triturate it in the amalgamator per the manufacturer's timing.\n\nWhy: Encapsulated capsules avoid bulk mercury handling, the single largest source of unnecessary mercury exposure in this step.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Load and triturate an encapsulated amalgam capsule",
          "why": "Encapsulated capsules avoid bulk mercury handling, the single largest source of unnecessary mercury exposure in this step."
        },
        {
          "detail": "Carry and condense amalgam into the cavity in increments, overfilling slightly for carving.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Condense amalgam into the preparation"
        },
        {
          "detail": "Carve grooves and cusp anatomy while the amalgam is still workable, then have the patient close gently to check contact.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Carve occlusal anatomy before set"
        },
        {
          "detail": "Once carving is complete, check bite marks in maximum intercuspation and excursions; adjust as needed.\n\nRecord: Occlusion checked, noted in the SOAP note",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Check occlusion with articulating paper"
        },
        {
          "detail": "Remove the dam or alternative isolation and rinse the patient's mouth.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Remove isolation"
        },
        {
          "detail": "Route all amalgam scrap and rinse water through the chairside amalgam separator; do not rinse amalgam waste to the sanitary sewer; collect scrap in the designated waste container.\n\nWhy: The EPA Dental Amalgam Effluent Rule requires separator capture of amalgam waste before it reaches wastewater.\n\nRecord: Amalgam waste routed through separator, facility log updated",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Handle amalgam waste through the separator system",
          "why": "The EPA Dental Amalgam Effluent Rule requires separator capture of amalgam waste before it reaches wastewater."
        },
        {
          "detail": "Explain numbness will wear off, avoid chewing on the treated side for 24 hours while the amalgam reaches full strength, and mild sensitivity is normal.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Log tooth, material (amalgam), capsule lot if tracked, isolation method, and occlusion check in the SOAP note.\n\nRecord: Procedure note with material and occlusion check",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Confirm the amalgam separator's maintenance/replacement schedule is current per the facility's environmental compliance log.\n\nRecord: Separator maintenance log entry",
          "id": "s15",
          "kind": "step",
          "role": "office-manager",
          "title": "Log periodic separator compliance check"
        },
        {
          "detail": "Restoration complete",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Restoration complete"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Amalgam restoration with mercury hygiene and separator compliance — Amalgam is selected for a posterior restoration in an eligible patient.",
      "title": "Amalgam restoration with mercury hygiene and separator compliance",
      "trigger": "Amalgam is selected for a posterior restoration in an eligible patient",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "EPA 40 CFR 441 Dental Amalgam Effluent Rule",
          "source": "EPA 40 CFR 441 Dental Amalgam Effluent Rule",
          "url": "https://www.epa.gov/eg/dental-effluent-guidelines"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (mercury vapor exposure control)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (mercury vapor exposure control)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        },
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.2 (in-repo amalgam basis)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.2 (in-repo amalgam basis)"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "per-patient",
      "id": "rdir-005",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "rubber dam",
        "high-volume evacuation (HVE) suction",
        "amalgam separator on the vacuum line",
        "carbide or diamond bur for sectioning",
        "replacement restorative material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm and document why the existing amalgam is being replaced (fracture, recurrent decay, marginal leakage, patient request) before starting.\n\nWhy: Removing sound amalgam without documented cause is a treatment-planning and consent issue, not just a clinical one.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the reason for removal",
          "why": "Removing sound amalgam without documented cause is a treatment-planning and consent issue, not just a clinical one."
        },
        {
          "detail": "Confirm signed consent covering removal of the existing restoration and the replacement material selected.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent for removal and replacement material.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent for removal and replacement material"
        },
        {
          "detail": "Review the chart for allergy to the local anesthetic or vasoconstrictor being used, cardiac disease, and MAOI or other relevant drug interactions before administering anesthesia.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm anesthetic and vasoconstrictor allergy/history before injecting"
        },
        {
          "detail": "Administer local anesthetic and confirm profound anesthesia before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Place a rubber dam before sectioning the amalgam; this is not optional for amalgam removal.\n\nWhy: Rubber dam prevents the patient from swallowing or aspirating amalgam fragments during sectioning.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Place rubber dam isolation",
          "why": "Rubber dam prevents the patient from swallowing or aspirating amalgam fragments during sectioning."
        },
        {
          "detail": "Position the HVE tip as close to the bur as possible throughout sectioning to capture aerosol and particulate.\n\nWhy: Sectioning old amalgam generates mercury-containing aerosol; close-range HVE captures it before it disperses.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Position high-volume evacuation close to the site",
          "why": "Sectioning old amalgam generates mercury-containing aerosol; close-range HVE captures it before it disperses."
        },
        {
          "detail": "Section the amalgam into segments with a bur under water spray and HVE, then remove segments with hand instruments rather than grinding to dust where possible.\n\nWhy: Removing in segments rather than grinding to powder reduces the amount of fine aerosol generated.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Section and remove the old restoration",
          "why": "Removing in segments rather than grinding to powder reduces the amount of fine aerosol generated."
        },
        {
          "detail": "Inspect and remove any recurrent decay found under the old restoration before placing the replacement.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Inspect the preparation for remaining decay"
        },
        {
          "detail": "Place the replacement material per the applicable direct restorative protocol for that material (composite or amalgam).",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Place the replacement restoration"
        },
        {
          "detail": "Remove the rubber dam and rinse the patient's mouth thoroughly.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Remove isolation and rinse"
        },
        {
          "detail": "Collect solid amalgam fragments in the designated waste container; confirm suction line waste passes through the amalgam separator, not directly to drain.\n\nRecord: Amalgam removal waste routed through separator, facility log updated",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Route amalgam fragments and evacuation waste through the separator"
        },
        {
          "detail": "Explain numbness will wear off and any care specific to the replacement material placed.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Log tooth, reason for removal, findings under the old restoration, and replacement material in the SOAP note.\n\nRecord: Procedure note with removal reason and replacement material",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Removal and replacement complete",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Removal and replacement complete"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Existing amalgam removal with aerosol and waste controls — A failing amalgam is being replaced.",
      "title": "Existing amalgam removal with aerosol and waste controls",
      "trigger": "A failing amalgam is being replaced",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite/restorative basis, generalized to glass ionomer)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite/restorative basis, generalized to glass ionomer)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (materials SDS)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (materials SDS)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "per-patient",
      "id": "rdir-006",
      "kind": "clinical",
      "materials": [
        "cotton roll or alternative isolation",
        "conditioner/dentin cleanser",
        "glass ionomer or RMGI capsules or hand-mix",
        "amalgamator or mixing pad",
        "curing light (RMGI only)",
        "finishing instruments"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the case fits the indication: root/cervical caries, high caries risk needing fluoride release, pediatric or limited-cooperation patient, or an interim restoration.\n\nWhy: Glass ionomer has lower wear resistance than composite, so it is chosen for its fluoride release and moisture tolerance, not as a default.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the indication for glass ionomer or RMGI",
          "why": "Glass ionomer has lower wear resistance than composite, so it is chosen for its fluoride release and moisture tolerance, not as a default."
        },
        {
          "detail": "Confirm consent discussion covers why glass ionomer or RMGI was selected, including that it may need future replacement with a more wear-resistant material.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent covering material choice.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent covering material choice"
        },
        {
          "detail": "Isolate with cotton rolls, retraction cord, or whatever isolation the patient's cooperation allows.\n\nWhy: Glass ionomer tolerates a less-than-ideal moisture field better than composite, which is part of why it is chosen here.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the field with available tolerance",
          "why": "Glass ionomer tolerates a less-than-ideal moisture field better than composite, which is part of why it is chosen here."
        },
        {
          "detail": "Remove caries with hand or slow-speed rotary instruments, preserving as much sound structure as possible.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Remove caries conservatively"
        },
        {
          "detail": "Apply the dentin conditioner per manufacturer timing, rinse, and dry without desiccating the surface.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Condition the tooth surface"
        },
        {
          "detail": "Mix the capsule or hand-mix per manufacturer ratio and timing, and place into the preparation before working time expires.\n\nWhy: Glass ionomer has a short working time; late placement produces a weak, granular set.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Mix and place the material",
          "why": "Glass ionomer has a short working time; late placement produces a weak, granular set."
        },
        {
          "detail": "Light-cure or chemical set?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "rmgi",
              "label": "RMGI — light-cure per manufacturer time"
            },
            {
              "goto": "s8",
              "id": "gi",
              "label": "Conventional glass ionomer — protect during chemical set"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Light-cure or chemical set?"
        },
        {
          "detail": "Contour and finish the restoration once fully set; avoid premature finishing on conventional glass ionomer before it reaches final set.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Shape and finish once set"
        },
        {
          "detail": "Remove isolation materials and rinse the patient's mouth.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Remove isolation and rinse"
        },
        {
          "detail": "Explain the material may need monitoring or eventual replacement, and note any diet guidance for the first hours after placement.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Log tooth, indication for material choice, and material used in the SOAP note.\n\nRecord: Procedure note with material and indication",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Restoration complete",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Restoration complete"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Glass ionomer / resin-modified glass ionomer restoration (root caries, pediatric, interim) — Root caries, a high-risk patient, or a non-cooperative patient where moisture control is limited.",
      "title": "Glass ionomer / resin-modified glass ionomer restoration (root caries, pediatric, interim)",
      "trigger": "Root caries, a high-risk patient, or a non-cooperative patient where moisture control is limited",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo restorative basis, generalized to hand-instrument technique)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo restorative basis, generalized to hand-instrument technique)"
        },
        {
          "kind": "open_standard",
          "label": "ADA patient-group guidance on minimally invasive restorative approaches (open)",
          "source": "ADA patient-group guidance on minimally invasive restorative approaches (open)"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rdir-007",
      "kind": "clinical",
      "materials": [
        "hand excavators (spoon excavators)",
        "glass ionomer restorative material",
        "cotton rolls",
        "petroleum jelly or similar surface protectant"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm and document the reason rotary instrumentation is not tolerated (young age, anxiety, medical/behavioral limitation) and that ART is the appropriate alternative rather than deferring to sedation.\n\nWhy: ART is chosen when it is the better option for this specific patient, not as a lower standard of care.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the patient cannot tolerate rotary instruments",
          "why": "ART is chosen when it is the better option for this specific patient, not as a lower standard of care."
        },
        {
          "detail": "Confirm consent from the caregiver (and age-appropriate assent from the patient where relevant) covering the hand-excavation technique and glass ionomer material.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent or assent for the ART approach.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent or assent for the ART approach"
        },
        {
          "detail": "Position the patient for comfort and use behavior-guidance techniques appropriate to age and cooperation level before starting.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Position and comfort the patient"
        },
        {
          "detail": "Place cotton rolls for basic moisture control; full isolation is often not tolerated in this population.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate with cotton rolls"
        },
        {
          "detail": "Use hand excavators to remove soft, cavitated caries without rotary instruments or local anesthetic in most cases.\n\nWhy: No rotary noise, vibration, or needle is the entire point of this technique for a non-cooperative patient.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Excavate caries by hand instrument only",
          "why": "No rotary noise, vibration, or needle is the entire point of this technique for a non-cooperative patient."
        },
        {
          "detail": "Is remaining dentin firm and the cavity accessible?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes",
              "label": "Yes — proceed to restoration"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "No — too deep or inaccessible for hand instruments alone"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is remaining dentin firm and the cavity accessible?"
        },
        {
          "detail": "Condition, mix and place glass ionomer into the prepared cavity, protecting it during set per the applicable glass ionomer protocol.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Place glass ionomer restoration"
        },
        {
          "detail": "Apply a surface protectant such as petroleum jelly and keep the patient from biting the area until initial set is reached.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Protect the surface during initial set"
        },
        {
          "detail": "Explain the restoration may need monitoring or replacement over time and give age-appropriate diet guidance for the rest of the day.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Give caregiver post-operative guidance"
        },
        {
          "detail": "Log tooth, cooperation-limitation reason, technique (ART), and material used in the SOAP note.\n\nRecord: Procedure note with ART indication and outcome",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "ART restoration complete or referral made",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "ART restoration complete or referral made"
        },
        {
          "detail": "Refer for a sedation consultation or specialist evaluation when hand excavation cannot safely complete the lesion.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Escalate to sedation option or specialist referral"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Atraumatic restorative treatment (hand excavation and glass ionomer) — A cavitated lesion in a patient who cannot tolerate rotary instruments.",
      "title": "Atraumatic restorative treatment (hand excavation and glass ionomer)",
      "trigger": "A cavitated lesion in a patient who cannot tolerate rotary instruments",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo restorative basis, generalized to deep-caries management)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo restorative basis, generalized to deep-caries management)"
        },
        {
          "kind": "open_standard",
          "label": "ADA patient-group guidance on vital pulp therapy approaches (open)",
          "source": "ADA patient-group guidance on vital pulp therapy approaches (open)"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "per-patient",
      "id": "rdir-008",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "isolation",
        "slow-speed rotary or hand excavators",
        "calcium hydroxide or bioceramic liner",
        "resin-modified glass ionomer base",
        "restorative material for the definitive/interim restoration"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm on the radiograph that caries approaches but does not clearly involve the pulp, and confirm the tooth is asymptomatic with a normal vitality test result.\n\nWhy: Selective removal and indirect pulp capping are indicated for a vital, asymptomatic tooth — a symptomatic or non-vital tooth needs a different treatment path.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review radiograph and confirm the tooth is asymptomatic and vital",
          "why": "Selective removal and indirect pulp capping are indicated for a vital, asymptomatic tooth — a symptomatic or non-vital tooth needs a different treatment path."
        },
        {
          "detail": "Confirm consent explicitly covers the possibility of pulp exposure during removal and what happens next if it occurs (direct pulp cap or referral for root canal evaluation).",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent covering exposure risk and possible next steps.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent covering exposure risk and possible next steps"
        },
        {
          "detail": "Review the chart for allergy to the local anesthetic or vasoconstrictor being used, cardiac disease, and MAOI or other relevant drug interactions before administering anesthesia.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm anesthetic and vasoconstrictor allergy/history before injecting"
        },
        {
          "detail": "Administer local anesthetic and confirm profound anesthesia before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Place a rubber dam or alternative isolation appropriate to the tooth.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the field"
        },
        {
          "detail": "Remove all caries at the peripheral walls and dentino-enamel junction completely, leaving affected but not infected dentin only over the deepest area near the pulp.\n\nWhy: A caries-free peripheral seal is what makes selective removal safe; the deep area is left selectively, not the whole lesion.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Remove caries at the periphery to a caries-free wall",
          "why": "A caries-free peripheral seal is what makes selective removal safe; the deep area is left selectively, not the whole lesion."
        },
        {
          "detail": "How does the deepest dentin look and feel?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "firm",
              "label": "Firm, discolored dentin over an intact roof — leave selectively"
            },
            {
              "goto": "s16",
              "id": "soft",
              "label": "Soft, wet dentin close to visible pulp — remove carefully and reassess for exposure"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "How does the deepest dentin look and feel?"
        },
        {
          "detail": "Place a calcium hydroxide or bioceramic liner directly over the retained affected dentin near the pulp.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Place a protective liner over the deepest dentin"
        },
        {
          "detail": "Place an RMGI base over the liner to seal and provide a stable foundation for the final restoration.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Place a resin-modified glass ionomer base"
        },
        {
          "detail": "Complete the restoration with the planned definitive or interim material per the applicable restorative protocol.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the restoration"
        },
        {
          "detail": "Remove isolation and rinse the patient's mouth.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Remove isolation and rinse"
        },
        {
          "detail": "Schedule a follow-up visit to reassess pulp vitality and symptoms, since selective removal carries a risk of pulpal involvement developing over time.\n\nWhy: Deep-caries management is a monitored decision, not a one-time procedure, until the pulp's long-term status is confirmed stable.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a pulp vitality follow-up",
          "why": "Deep-caries management is a monitored decision, not a one-time procedure, until the pulp's long-term status is confirmed stable."
        },
        {
          "detail": "Explain numbness will wear off and instruct the patient to call promptly if spontaneous pain, swelling, or prolonged sensitivity develops before the follow-up.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-operative instructions"
        },
        {
          "detail": "Log tooth, radiographic findings, removal decision (selective vs. exposure), liner/base materials, and follow-up plan in the SOAP note.\n\nRecord: Procedure note with selective-removal decision and follow-up plan",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Deep caries management complete, follow-up scheduled",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Deep caries management complete, follow-up scheduled"
        },
        {
          "detail": "Did a pulp exposure occur?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no",
              "label": "No exposure — proceed to liner placement"
            },
            {
              "goto": "s17",
              "id": "yes",
              "label": "Yes — exposure occurred"
            }
          ],
          "id": "s16",
          "kind": "fork",
          "role": "dentist",
          "title": "Did a pulp exposure occur?"
        },
        {
          "detail": "Stop selective removal and follow the direct pulp cap protocol (rdir-009) for the exposure that just occurred.",
          "id": "s17",
          "kind": "step",
          "role": "dentist",
          "title": "Switch to the direct pulp cap protocol"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Deep caries — selective removal, liner/base and indirect pulp cap decision — Caries approaches the pulp radiographically and the tooth is asymptomatic.",
      "title": "Deep caries — selective removal, liner/base and indirect pulp cap decision",
      "trigger": "Caries approaches the pulp radiographically and the tooth is asymptomatic",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "No ADA/FDA public-domain guidance found on direct pulp-capping technique — the amalgam patient-group and whitening-safety guidance cited are real but address unrelated topics — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "The source's own prior text: 'noted for transparency that it has no direct topical connection to direct pulp capping technique.' Independent confirmation: ADA/FDA amalgam patient-group guidance and FDA/ADA whitening-safety guidance are both real documents, but neither addresses pulpal exposure management.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA/FDA amalgam patient-group guidance and FDA/ADA whitening safety guidance (open) — cited as this class's designated public-domain-floor entry; noted for transparency that it has no direct topical connection to direct pulp capping technique, which otherwise rests on the generic entry below",
              "url": null
            }
          },
          "source": "No applicable authority for direct pulp-capping technique — generic functional equivalent"
        },
        {
          "kind": "generic",
          "label": "Direct pulp cap decision-making; esthetic consultation; smile-design wax-up/mock-up — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "'### 4.1 Composite Resin Restoration (Direct) \\n1. Shade selection before isolation (tooth dehydrates under rubber dam)... ### 4.2 Amalgam Restoration \\n- Increasingly uncommon; restricted by California... Mercury hygiene...' (DOCS/TECHNICAL_PROTOCOLS.md, quoted by the audit and re-read directly). rdir-015 (esthetic consultation) is described in the audit note as 12 steps of exam/options/cost-estimate/consent/handoff with no restorative step; rdir-016 (wax-up/mock-up) hands off to a separate definitive-restorative protocol afterward; rdir-009's exposure-assessment, hemostasis, and capping-material-placement steps are pulp-cap-specific and are not addressed by §4.1-4.2 either.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo composite and amalgam basis); smile design worksheets are generic functional equivalents",
              "url": null
            }
          },
          "source": "No authority covers this set. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 is a composite/amalgam filling-technique protocol; it touches, at most, one tail restorative step of rdir-009 and has no bearing on rdir-015 or rdir-016 — generic functional equivalent for the pulp-cap decision, esthetic-consultation, and wax-up/mock-up steps"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for a direct pulp cap sequence — no institute protocol reproduced; sequence reflects the standard hemostasis → liner → seal pattern taught in dental education",
          "source": "Generic functional equivalent for a direct pulp cap sequence — no institute protocol reproduced; sequence reflects the standard hemostasis → liner → seal pattern taught in dental education"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rdir-009",
      "kind": "clinical",
      "materials": [
        "hemostatic agent",
        "calcium hydroxide or calcium silicate direct pulp cap material",
        "rubber dam",
        "sterile cotton pellets",
        "restorative material for final seal"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Stop caries removal at first sign of exposure. Note whether the exposure is pinpoint (<1mm), whether bleeding is easily controlled, and whether the field was contaminated by saliva or debris before isolation.\n\nWhy: A small, easily hemostatic exposure on a healthy vital tooth is the case selection that makes a direct cap likely to succeed; a large or contaminated exposure changes the plan.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Assess exposure size, bleeding and contamination",
          "why": "A small, easily hemostatic exposure on a healthy vital tooth is the case selection that makes a direct cap likely to succeed; a large or contaminated exposure changes the plan."
        },
        {
          "detail": "Dentist confirms rubber dam or equivalent isolation is in place and the field is dry before any capping material is placed; if isolation cannot be achieved, treatment plan is reconsidered (indirect cap, staged approach, or referral) rather than proceeding.\n\nWhy: Saliva contamination of the capping material is a documented cause of direct pulp cap failure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm isolation is adequate before placing the cap.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm isolation is adequate before placing the cap",
          "why": "Saliva contamination of the capping material is a documented cause of direct pulp cap failure."
        },
        {
          "detail": "Is this exposure a good candidate for a direct pulp cap?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "good-candidate",
              "label": "Pinpoint exposure, easy hemostasis, healthy vital pulp, adequate isolation"
            },
            {
              "goto": "s10",
              "id": "poor-candidate",
              "label": "Large exposure, uncontrolled bleeding, symptomatic pulp, or contamination"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this exposure a good candidate for a direct pulp cap?"
        },
        {
          "detail": "Apply a hemostatic agent on a sterile cotton pellet with light pressure; avoid scrubbing the exposure site or using caustic agents that can damage pulp tissue.\n\nWhy: Bleeding control that respects the pulp tissue, rather than mechanically traumatizing it, preserves the pulp's healing capacity.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Achieve hemostasis with a gentle hemostatic agent",
          "why": "Bleeding control that respects the pulp tissue, rather than mechanically traumatizing it, preserves the pulp's healing capacity."
        },
        {
          "detail": "Apply the calcium hydroxide or calcium silicate material in a thin layer directly over and slightly beyond the exposure site per the manufacturer's setting instructions.\n\nWhy: The capping material forms the biologic seal that supports dentin bridge formation.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Place the direct pulp cap material over the exposure",
          "why": "The capping material forms the biologic seal that supports dentin bridge formation."
        },
        {
          "detail": "Place a resin-modified glass ionomer or equivalent base over the capping material, then complete the restoration in the same visit unless the plan calls for a staged interim restoration.\n\nWhy: A coronal seal that resists microleakage is as important to success as the capping material itself.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Place a protective base and complete the definitive or interim restoration",
          "why": "A coronal seal that resists microleakage is as important to success as the capping material itself."
        },
        {
          "detail": "Chart the exposure details, materials used and post-op instructions given today.\n\nRecord: Tooth number, exposure size/location, hemostasis time, capping material and lot, base and restorative material, and post-op instructions given.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Document the exposure and materials used"
        },
        {
          "detail": "Front desk schedules a follow-up visit (commonly 4-6 weeks and again near 6-12 months — a conventional interval not attributed to a sourced public-domain guideline in this protocol; confirm current recommended timing independently) for pulp vitality and radiographic re-check; patient given return-if-symptomatic instructions in the interim.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule vitality re-check"
        },
        {
          "detail": "Direct pulp cap completed and follow-up scheduled",
          "id": "s9",
          "kind": "step",
          "title": "Direct pulp cap completed and follow-up scheduled"
        },
        {
          "detail": "Chart the reason the exposure did not meet direct-cap criteria and the alternative plan chosen.\n\nRecord: Reason the exposure did not meet direct-cap criteria, the alternative plan discussed (indirect cap, pulpotomy, referral), and patient/guardian discussion.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the change in treatment plan"
        },
        {
          "detail": "Case redirected to an alternative treatment plan",
          "id": "s11",
          "kind": "step",
          "title": "Case redirected to an alternative treatment plan"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Direct pulp cap after a small mechanical or carious exposure — A pinpoint pulp exposure occurs during caries removal on a vital tooth.",
      "title": "Direct pulp cap after a small mechanical or carious exposure",
      "trigger": "A pinpoint pulp exposure occurs during caries removal on a vital tooth",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/FDA amalgam patient-group guidance and FDA/ADA whitening safety guidance (open) — cited as this class's designated public-domain-floor entry; noted for transparency that it has no direct topical connection to the resin infiltration technique, which otherwise rests on the generic entry below",
          "source": "ADA/FDA amalgam patient-group guidance and FDA/ADA whitening safety guidance (open) — cited as this class's designated public-domain-floor entry; noted for transparency that it has no direct topical connection to the resin infiltration technique, which otherwise rests on the generic entry below"
        },
        {
          "kind": "generic",
          "label": "For a resin infiltration sequence — no vendor product protocol reproduced; the etch-dry-infiltrate-cure pattern is the widely taught technique class — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a resin infiltration sequence — no vendor product protocol reproduced; the etch-dry-infiltrate-cure pattern is the widely taught technique class"
          },
          "source": "For a resin infiltration sequence — no vendor product protocol reproduced; the etch-dry-infiltrate-cure pattern is the widely taught technique class — Practice policy — no published authority governs this step."
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rdir-011",
      "kind": "clinical",
      "materials": [
        "etching gel (hydrochloric acid based, per product labeling)",
        "resin infiltrant",
        "isolation supplies (rubber dam or wedges)",
        "curing light",
        "polishing discs"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Verify with an explorer and, for interproximal lesions, a radiograph that the enamel surface is intact (no cavitation) and the lesion depth is limited to outer/mid enamel.\n\nWhy: Resin infiltration is indicated only for intact, non-cavitated lesions; a cavitated lesion needs a different restorative approach.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the lesion is non-cavitated and radiographically appropriate",
          "why": "Resin infiltration is indicated only for intact, non-cavitated lesions; a cavitated lesion needs a different restorative approach."
        },
        {
          "detail": "Photograph the lesion under consistent lighting before treatment for later comparison of esthetic result.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Take a baseline photograph of the lesion"
        },
        {
          "detail": "Dentist explains that resin infiltration arrests the lesion and often improves but does not guarantee complete disappearance of the white-spot appearance, and confirms the patient accepts that expectation before proceeding.\n\nWhy: Mismatched expectations about the esthetic outcome are the most common source of patient dissatisfaction with this procedure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient understands expected outcome before treatment.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm patient understands expected outcome before treatment",
          "why": "Mismatched expectations about the esthetic outcome are the most common source of patient dissatisfaction with this procedure."
        },
        {
          "detail": "Place rubber dam or interproximal wedges/matrix as appropriate to the lesion location to keep the etchant and infiltrant off adjacent soft tissue and teeth.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the field"
        },
        {
          "detail": "Apply the etching gel per product labeling to open the porous surface layer of the lesion, then rinse and dry thoroughly.\n\nWhy: Etching removes the intact surface layer that would otherwise block the infiltrant from reaching the lesion body.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Etch the lesion surface",
          "why": "Etching removes the intact surface layer that would otherwise block the infiltrant from reaching the lesion body."
        },
        {
          "detail": "A lesion that stays chalky white after etching and drying indicates the porosity was reached and the case is ready for infiltrant; if the etch did not change the appearance, an additional etch cycle may be needed.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "ready",
              "label": "Lesion appearance responded to etch — proceed to infiltrant"
            },
            {
              "goto": "s5",
              "id": "re-etch",
              "label": "No change — repeat etch cycle"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the lesion still appear white when dried (before infiltrant)?"
        },
        {
          "detail": "Apply the infiltrant per manufacturer instructions, allow the stated penetration time, remove excess, and light-cure.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Apply and cure the resin infiltrant"
        },
        {
          "detail": "Is a second infiltration cycle needed for full esthetic effect?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "one-cycle-sufficient",
              "label": "One cycle achieved acceptable esthetics"
            },
            {
              "goto": "s7",
              "id": "repeat-cycle",
              "label": "Lesion still visible — repeat the infiltration cycle"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a second infiltration cycle needed for full esthetic effect?"
        },
        {
          "detail": "Polish any excess cured resin flush with the enamel surface, then photograph under the same conditions as the baseline photo.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Polish the surface and take a post-treatment photograph"
        },
        {
          "detail": "Chart the lesion location, cycle count and before/after photographs taken today.\n\nRecord: Lesion location, number of etch/infiltration cycles, before/after photographs, and patient-reported satisfaction.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Document the procedure and outcome"
        },
        {
          "detail": "Front desk schedules a follow-up visit (commonly at the next recall) to confirm the lesion remains arrested and compare photographs.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up recheck"
        },
        {
          "detail": "Resin infiltration completed and follow-up scheduled",
          "id": "s12",
          "kind": "step",
          "title": "Resin infiltration completed and follow-up scheduled"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Resin infiltration of non-cavitated white-spot lesions — Post-orthodontic or interproximal non-cavitated lesions where arrest and esthetics are wanted.",
      "title": "Resin infiltration of non-cavitated white-spot lesions",
      "trigger": "Post-orthodontic or interproximal non-cavitated lesions where arrest and esthetics are wanted",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=651",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for a minimally-invasive repair-first decision framework — no institute checklist reproduced; repair-first is a widely taught minimally-invasive principle",
          "source": "Generic functional equivalent for a minimally-invasive repair-first decision framework — no institute checklist reproduced; repair-first is a widely taught minimally-invasive principle"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rdir-013",
      "kind": "clinical",
      "materials": [
        "explorer and mirror",
        "radiograph as needed",
        "shade guide",
        "repair or replacement restorative materials as decided"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Use explorer, mirror and radiograph as needed to determine whether the finding is marginal staining, a small chip, marginal gap, or secondary caries, and how many surfaces or how much of the restoration margin are involved.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify and characterize the defect"
        },
        {
          "detail": "Is active secondary caries present under or beside the restoration?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-caries",
              "label": "No active caries — defect is cosmetic or minor marginal wear"
            },
            {
              "goto": "s3",
              "id": "caries-present",
              "label": "Active caries confirmed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is active secondary caries present under or beside the restoration?"
        },
        {
          "detail": "A localized marginal defect or small area of secondary caries on an otherwise sound, well-bonded restoration favors repair; extensive caries, a fractured restoration, or multiple failing margins favor full replacement.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "repair",
              "label": "Localized defect — repair in place"
            },
            {
              "goto": "s4",
              "id": "replace",
              "label": "Extensive defect or multiple failing margins — full replacement"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the defect localized enough to repair rather than fully replace?"
        },
        {
          "detail": "Dentist confirms the repair-vs-replace decision and clinical rationale are sound before any tooth structure is removed — this is the point past which the choice determines how much of the tooth is committed.\n\nWhy: Choosing replacement when repair would have sufficed removes sound tooth structure unnecessarily; the reverse risks a premature re-failure — the sign-off forces a deliberate check before either happens.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the repair-vs-replace call before proceeding.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the repair-vs-replace call before proceeding",
          "why": "Choosing replacement when repair would have sufficed removes sound tooth structure unnecessarily; the reverse risks a premature re-failure — the sign-off forces a deliberate check before either happens."
        },
        {
          "detail": "Proceed with the chosen path",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "go-repair",
              "label": "Proceed with repair"
            },
            {
              "goto": "s10",
              "id": "go-replace",
              "label": "Proceed with replacement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Proceed with the chosen path"
        },
        {
          "detail": "Confirm the patient or caregiver understands and accepts the localized-repair approach chosen before any tooth structure is touched.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient/caregiver consent to the repair before treatment.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm patient/caregiver consent to the repair before treatment"
        },
        {
          "detail": "Remove only the defective portion and any caries present, roughen and bond to the sound existing restoration margin, and place new material limited to the repaired area.\n\nWhy: A repair that removes only the defective portion preserves more sound tooth structure than a full replacement.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Perform a localized repair",
          "why": "A repair that removes only the defective portion preserves more sound tooth structure than a full replacement."
        },
        {
          "detail": "Chart the decision made, the clinical rationale, and the materials used today.\n\nRecord: Findings on assessment, decision made (repair or replace) and the clinical rationale, materials used, and patient discussion of the plan.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the repair-vs-replace decision and rationale"
        },
        {
          "detail": "Repair-versus-replace decision documented and treatment completed",
          "id": "s9",
          "kind": "step",
          "title": "Repair-versus-replace decision documented and treatment completed"
        },
        {
          "detail": "Confirm the patient or caregiver understands and accepts the full-replacement approach chosen, including that it is a more substantive and irreversible procedure than a repair, before the existing restoration is removed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient/caregiver consent to full replacement before treatment.",
            "type": "safety"
          },
          "id": "s10",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm patient/caregiver consent to full replacement before treatment"
        },
        {
          "detail": "Remove the full existing restoration, re-evaluate remaining tooth structure and pulp status, and place a new restoration per the applicable class protocol (e.g. rdir-001/002).",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Remove the existing restoration and replace fully"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Repair-versus-replace decision for a defective restoration — A marginal defect, chip or secondary caries is found on an existing restoration.",
      "title": "Repair-versus-replace decision for a defective restoration",
      "trigger": "A marginal defect, chip or secondary caries is found on an existing restoration",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA/FDA amalgam patient-group guidance and FDA/ADA whitening safety guidance (open) — cited as this class's designated public-domain-floor entry; noted for transparency that it has no direct topical connection to occlusal adjustment technique, which otherwise rests on the generic entry below",
          "source": "ADA/FDA amalgam patient-group guidance and FDA/ADA whitening safety guidance (open) — cited as this class's designated public-domain-floor entry; noted for transparency that it has no direct topical connection to occlusal adjustment technique, which otherwise rests on the generic entry below"
        },
        {
          "kind": "generic",
          "label": "For an occlusal adjustment recall visit — no institute checklist reproduced; articulating-paper high-spot marking is a standard clinical technique — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for an occlusal adjustment recall visit — no institute checklist reproduced; articulating-paper high-spot marking is a standard clinical technique"
          },
          "source": "For an occlusal adjustment recall visit — no institute checklist reproduced; articulating-paper high-spot marking is a standard clinical technique — Practice policy — no published authority governs this step."
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rdir-014",
      "kind": "clinical",
      "materials": [
        "articulating paper",
        "occlusal adjustment burs and polishing discs",
        "cold test materials if sensitivity assessment needed"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Front desk asks whether the tooth hurts only on biting (suggests high spot), lingers with hot/cold (suggests pulpal involvement), or there is swelling; book a prompt adjustment visit and flag pulpal symptoms to the dentist before the visit.\n\nWhy: Distinguishing a mechanical high-spot complaint from a developing pulpal problem at intake avoids a wasted adjustment visit when the real issue is different.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the complaint at the front desk and screen for urgency",
          "why": "Distinguishing a mechanical high-spot complaint from a developing pulpal problem at intake avoids a wasted adjustment visit when the real issue is different."
        },
        {
          "detail": "Book the patient into a short adjustment slot, typically within 24-48 hours, since occlusal discomfort tends to worsen the longer it is left uncorrected.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a prompt short visit"
        },
        {
          "detail": "Visually and radiographically (if indicated) re-check the restoration for a high spot, open margin, or other visible cause before adjusting anything.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Re-examine the restoration and surrounding tissue"
        },
        {
          "detail": "Have the patient bite in centric and lateral excursions on articulating paper; identify marks on the new restoration that are heavier or more numerous than on adjacent teeth.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Mark and identify the high spot with articulating paper"
        },
        {
          "detail": "Is a clear premature contact identified on the restoration?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "high-spot-found",
              "label": "Clear high spot on the restoration"
            },
            {
              "goto": "s11",
              "id": "no-clear-high-spot",
              "label": "No clear occlusal cause — symptoms suggest pulpal involvement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a clear premature contact identified on the restoration?"
        },
        {
          "detail": "Dentist confirms the identified high spot is the correct site to adjust before removing any tooth structure, since occlusal reduction of enamel cannot be undone.\n\nWhy: Occlusal adjustment is an irreversible removal of tooth structure — confirming the right spot before cutting avoids grinding a site that was not actually the problem.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the adjustment plan before removing tooth structure.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the adjustment plan before removing tooth structure",
          "why": "Occlusal adjustment is an irreversible removal of tooth structure — confirming the right spot before cutting avoids grinding a site that was not actually the problem."
        },
        {
          "detail": "Reduce the marked high spot with a fine bur, re-check with articulating paper, and repeat in small increments until contacts are even with adjacent teeth; polish the adjusted surface.\n\nWhy: Adjusting in small increments and re-checking avoids overcorrecting into a low spot on the opposite side.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Adjust the occlusion in small increments",
          "why": "Adjusting in small increments and re-checking avoids overcorrecting into a low spot on the opposite side."
        },
        {
          "detail": "Have the patient tap and chew naturally to confirm the high-bite sensation is resolved before dismissing.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the patient is comfortable biting"
        },
        {
          "detail": "Chart whether a high spot was found and adjusted, or the pulpal workup findings instead.\n\nRecord: Complaint, examination findings, whether a high spot was found and adjusted, or pulpal workup findings and next steps.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Document the visit findings and action taken"
        },
        {
          "detail": "Post-restoration adjustment visit completed",
          "id": "s10",
          "kind": "step",
          "title": "Post-restoration adjustment visit completed"
        },
        {
          "detail": "Perform cold and percussion testing and radiographic review; if findings suggest pulpal involvement, hand off to the deep-caries or endodontic evaluation pathway rather than continuing occlusal adjustment.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Proceed to a pulpal status workup"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Post-restoration high bite or sensitivity adjustment visit — A patient calls that the bite feels high or the tooth hurts on chewing after a filling.",
      "title": "Post-restoration high bite or sensitivity adjustment visit",
      "trigger": "A patient calls that the bite feels high or the tooth hurts on chewing after a filling",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=651",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "Direct pulp cap decision-making; esthetic consultation; smile-design wax-up/mock-up — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "'### 4.1 Composite Resin Restoration (Direct) \\n1. Shade selection before isolation (tooth dehydrates under rubber dam)... ### 4.2 Amalgam Restoration \\n- Increasingly uncommon; restricted by California... Mercury hygiene...' (DOCS/TECHNICAL_PROTOCOLS.md, quoted by the audit and re-read directly). rdir-015 (esthetic consultation) is described in the audit note as 12 steps of exam/options/cost-estimate/consent/handoff with no restorative step; rdir-016 (wax-up/mock-up) hands off to a separate definitive-restorative protocol afterward; rdir-009's exposure-assessment, hemostasis, and capping-material-placement steps are pulp-cap-specific and are not addressed by §4.1-4.2 either.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo composite and amalgam basis); smile design worksheets are generic functional equivalents",
              "url": null
            }
          },
          "source": "No authority covers this set. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 is a composite/amalgam filling-technique protocol; it touches, at most, one tail restorative step of rdir-009 and has no bearing on rdir-015 or rdir-016 — generic functional equivalent for the pulp-cap decision, esthetic-consultation, and wax-up/mock-up steps"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rdir-015",
      "kind": "clinical",
      "materials": [
        "intraoral and extraoral photographs",
        "shade guide",
        "consultation worksheet (generic functional equivalent)",
        "cost estimate template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ask open-ended questions about what specifically bothers the patient about their smile and what outcome they are hoping for, before offering any clinical opinion.\n\nWhy: Understanding the patient's own language and priorities first prevents the team from proposing a plan that solves a problem the patient did not identify.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Gather the patient's stated concerns and goals in their own words",
          "why": "Understanding the patient's own language and priorities first prevents the team from proposing a plan that solves a problem the patient did not identify."
        },
        {
          "detail": "Examine tooth color, alignment, gingival architecture, lip line and smile symmetry relevant to the stated concerns; take intraoral and extraoral photographs for the record.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Perform a focused esthetic clinical exam"
        },
        {
          "detail": "Watch for expectations disproportionate to what any treatment can achieve, focus on a minor or imperceptible flaw, or history of dissatisfaction with prior cosmetic work elsewhere — these warrant a slower, more explicit expectation-setting conversation.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-red-flags",
              "label": "Expectations appear realistic and achievable"
            },
            {
              "goto": "s11",
              "id": "red-flags-present",
              "label": "Red flags present — needs explicit expectation-setting before proceeding"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Are there red flags suggesting unrealistic expectations?"
        },
        {
          "detail": "Cover: options ranging from minimally invasive (whitening, bonding, resin infiltration) to more involved (veneers, crowns); expected number of visits; approximate cost range for each option; risks and limitations of each; and how the options compare to the patient's stated goal.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present treatment options with the treatment coordinator"
        },
        {
          "detail": "Provide a written, itemized estimate for the option(s) the patient is considering, noting it is an estimate subject to change if the treatment plan changes.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Provide a written cost estimate"
        },
        {
          "detail": "Chart the patient's stated goals, options presented and any expectation-setting conversation held.\n\nRecord: Patient's stated concerns and goals, exam findings, photographs taken, options presented, and any expectation-setting conversation held.",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the consultation"
        },
        {
          "detail": "Does the patient want to proceed now?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "proceed",
              "label": "Patient wants to schedule treatment"
            },
            {
              "goto": "s12",
              "id": "think-about-it",
              "label": "Patient wants time to decide"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient want to proceed now?"
        },
        {
          "detail": "Dentist confirms the patient's written estimate, expected outcome, risks and limitations were reviewed and understood before treatment is scheduled.\n\nWhy: Consent captured at the moment of committing to treatment, not just during the general discussion, is what protects against a later dispute over what was promised.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm informed consent before scheduling any cosmetic treatment.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm informed consent before scheduling any cosmetic treatment",
          "why": "Consent captured at the moment of committing to treatment, not just during the general discussion, is what protects against a later dispute over what was promised."
        },
        {
          "detail": "Treatment coordinator schedules the accepted case and, if the plan includes smile-design records, hands off to the smile design records protocol.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to treatment planning and scheduling"
        },
        {
          "detail": "Esthetic case accepted and scheduled",
          "id": "s10",
          "kind": "step",
          "title": "Esthetic case accepted and scheduled"
        },
        {
          "detail": "Show comparable before/after examples honestly labeled as prior cases (per advertising rules, never implying a guarantee), explain what treatment can and cannot change, and consider a cooling-off period before treatment is scheduled if concerns remain.\n\nWhy: Slowing down here reduces the risk of an unhappy patient after treatment that was technically successful but did not meet an unrealistic expectation.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hold an explicit expectation-setting conversation",
          "why": "Slowing down here reduces the risk of an unhappy patient after treatment that was technically successful but did not meet an unrealistic expectation."
        },
        {
          "detail": "Consultation completed, decision pending with the patient",
          "id": "s12",
          "kind": "step",
          "title": "Consultation completed, decision pending with the patient"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Esthetic consultation — concerns, expectations, red flags for unrealistic goals — A patient requests a cosmetic improvement.",
      "title": "Esthetic consultation — concerns, expectations, red flags for unrealistic goals",
      "trigger": "A patient requests a cosmetic improvement",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=651",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "Direct pulp cap decision-making; esthetic consultation; smile-design wax-up/mock-up — generic functional equivalent",
          "repaired": {
            "action": "generic",
            "evidence": "'### 4.1 Composite Resin Restoration (Direct) \\n1. Shade selection before isolation (tooth dehydrates under rubber dam)... ### 4.2 Amalgam Restoration \\n- Increasingly uncommon; restricted by California... Mercury hygiene...' (DOCS/TECHNICAL_PROTOCOLS.md, quoted by the audit and re-read directly). rdir-015 (esthetic consultation) is described in the audit note as 12 steps of exam/options/cost-estimate/consent/handoff with no restorative step; rdir-016 (wax-up/mock-up) hands off to a separate definitive-restorative protocol afterward; rdir-009's exposure-assessment, hemostasis, and capping-material-placement steps are pulp-cap-specific and are not addressed by §4.1-4.2 either.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo composite and amalgam basis); smile design worksheets are generic functional equivalents",
              "url": null
            }
          },
          "source": "No authority covers this set. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 is a composite/amalgam filling-technique protocol; it touches, at most, one tail restorative step of rdir-009 and has no bearing on rdir-015 or rdir-016 — generic functional equivalent for the pulp-cap decision, esthetic-consultation, and wax-up/mock-up steps"
        },
        {
          "kind": "generic",
          "label": "For a diagnostic wax-up and intraoral mock-up sequence — no institute smile-design system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a diagnostic wax-up and intraoral mock-up sequence — no institute smile-design system reproduced"
          },
          "source": "For a diagnostic wax-up and intraoral mock-up sequence — no institute smile-design system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "rdir-016",
      "kind": "clinical",
      "materials": [
        "digital or conventional impressions/scan",
        "photographs (facial, retracted, close-up)",
        "diagnostic wax-up (lab-fabricated)",
        "mock-up putty matrix and bis-acryl or flowable trial material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Take a full-arch impression or digital scan, facial and retracted photographs, and shade photographs under consistent lighting.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Capture full diagnostic records"
        },
        {
          "detail": "Lab liaison forwards the records with the dentist's prescription describing the desired esthetic changes (shape, length, alignment) for the diagnostic wax-up.",
          "id": "s2",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send records to the lab liaison for wax-up fabrication"
        },
        {
          "detail": "Typical turnaround is 3-5 business days; lab liaison tracks the case and follows up if it runs past the expected date.",
          "id": "s3",
          "kind": "timer",
          "role": "lab-liaison",
          "timer_seconds": 432000,
          "title": "Wait for the diagnostic wax-up to return from the lab"
        },
        {
          "detail": "Make a putty index of the wax-up model to use for the intraoral mock-up.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Fabricate the putty matrix from the wax-up"
        },
        {
          "detail": "Load the matrix with bis-acryl or flowable trial material and seat it over the patient's teeth without bonding, allow it to set, and remove flash so the patient can see and feel the proposed result.\n\nWhy: A reversible intraoral trial lets the patient evaluate the proposed change on their own face and speech before any tooth structure is altered.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Trial the mock-up intraorally",
          "why": "A reversible intraoral trial lets the patient evaluate the proposed change on their own face and speech before any tooth structure is altered."
        },
        {
          "detail": "Photograph the mock-up in place, have the patient view it in a mirror and speak/smile naturally, and record specific feedback (shape, length, color impression).",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Photograph the mock-up and gather patient feedback"
        },
        {
          "detail": "Does the patient approve the mock-up as planned?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "approved",
              "label": "Patient approves the design"
            },
            {
              "goto": "s12",
              "id": "revise",
              "label": "Patient requests changes"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient approve the mock-up as planned?"
        },
        {
          "detail": "Dentist confirms the patient understands the definitive treatment plan matches the approved mock-up, reviews risks/limitations, and obtains signed consent before any irreversible tooth preparation begins.\n\nWhy: The mock-up is reversible; converting it to definitive treatment (preparation, bonding) is not, so consent is captured at this transition point specifically.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm informed consent before converting the mock-up into definitive treatment.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm informed consent before converting the mock-up into definitive treatment",
          "why": "The mock-up is reversible; converting it to definitive treatment (preparation, bonding) is not, so consent is captured at this transition point specifically."
        },
        {
          "detail": "Chart the approved mock-up photographs and the signed consent for definitive treatment.\n\nRecord: Approved mock-up photographs, signed consent for definitive treatment, and the finalized treatment plan referencing the approved design.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Document final approval and consent"
        },
        {
          "detail": "Front desk/treatment coordinator schedules the definitive treatment visit(s) referencing the approved wax-up as the clinical target.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to the scheduled definitive restorative or prosthetic protocol"
        },
        {
          "detail": "Smile design records approved and case handed to definitive treatment",
          "id": "s11",
          "kind": "step",
          "title": "Smile design records approved and case handed to definitive treatment"
        },
        {
          "detail": "Chart the specific requested changes and annotated photographs sent back to the lab.\n\nRecord: Specific feedback on what to change (length, shape, symmetry) and photographs annotated with the requested changes.",
          "id": "s12",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Document requested changes and send back to the lab"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Smile design records, diagnostic wax-up and intraoral mock-up trial — An esthetic case is accepted for planning and the patient wants to preview the result before committing.",
      "title": "Smile design records, diagnostic wax-up and intraoral mock-up trial",
      "trigger": "An esthetic case is accepted for planning and the patient wants to preview the result before committing",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "Class taxonomy floor: FDA/ADA whitening safety guidance (open)",
          "source": "Class taxonomy floor: FDA/ADA whitening safety guidance (open)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (peroxide gel SDS)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (peroxide gel SDS)",
          "url": "https://www.osha.gov/hazcom"
        },
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims"
        },
        {
          "kind": "generic",
          "label": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — generic functional equivalent for the whitening/bleaching protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "DOCS/TECHNICAL_PROTOCOLS.md §4.1 reads: 'Shade selection before isolation (tooth dehydrates under rubber dam)...' (composite steps); §4.2 covers amalgam trituration, mercury hygiene, and the CA amalgam-separator mandate. Neither section, read in full, mentions whitening, bleaching agents, tray fabrication, gel application, or bleaching-related sensitivity/chemical-burn management. A repo-wide grep for 'whitening' and 'bleach' across DOCS/*.md returns no dedicated clinical-protocol document for in-office/take-home/internal whitening.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo restorative/whitening basis)",
              "url": null
            }
          },
          "source": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step."
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-patient",
      "id": "rdir-017",
      "kind": "clinical",
      "materials": [
        "shade guide",
        "protective eyewear",
        "gingival barrier / dam material",
        "lip and cheek retractor",
        "high-concentration peroxide whitening gel",
        "curing/whitening light if used per manufacturer instructions",
        "desensitizing gel or fluoride varnish"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm no active caries, exposed dentin, defective restorations, or untreated gum disease; note existing crowns/veneers/fillings that will not lighten and will not match whitened enamel.\n\nWhy: Whitening over untreated decay or leaking margins can drive peroxide into the pulp or under a restoration margin.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Screen candidacy before scheduling gel application",
          "why": "Whitening over untreated decay or leaking margins can drive peroxide into the pulp or under a restoration margin."
        },
        {
          "detail": "Confirm signed consent covering expected shade change, temporary sensitivity, the shade-mismatch limitation on existing restorations, and pregnancy/nursing deferral.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent including shade-mismatch and sensitivity risk.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent including shade-mismatch and sensitivity risk"
        },
        {
          "detail": "Take a shade-guide reading and a reference photo before any gel is applied.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Record baseline shade and photo"
        },
        {
          "detail": "Confirm protective eyewear is placed on the patient, retract lips and cheeks, dry the teeth, and apply a light-cured gingival barrier or dam over the gum margins to keep gel off soft tissue.\n\nWhy: Concentrated peroxide gel on unprotected gingiva causes a chemical burn.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Place lip/cheek retraction and gingival barrier",
          "why": "Concentrated peroxide gel on unprotected gingiva causes a chemical burn."
        },
        {
          "detail": "Visually inspect the barrier margin around each tooth for gaps before the assistant applies gel.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm barrier seal before gel goes on"
        },
        {
          "detail": "Apply gel to the facial surfaces of the teeth being whitened and time each application cycle exactly as the product instructions specify, activating a light only if the product calls for one.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Apply whitening gel per manufacturer's timed cycles"
        },
        {
          "detail": "Watch the patient and the barrier margins throughout each timed cycle; stop immediately and rinse if the patient reports burning or blanching is seen at the gumline.",
          "id": "s7",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 900,
          "title": "Time each gel cycle and check for tissue irritation"
        },
        {
          "detail": "Continue to another gel cycle or stop?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "another-cycle",
              "label": "No irritation, shade goal not yet reached — repeat the cycle"
            },
            {
              "goto": "s9",
              "id": "stop",
              "label": "Irritation present or shade goal reached — stop and rinse"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Continue to another gel cycle or stop?"
        },
        {
          "detail": "Suction and wipe residual gel, remove the gingival barrier, and rinse the mouth thoroughly.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Remove gel and barrier, rinse thoroughly"
        },
        {
          "detail": "Take a shade-guide reading and comparison photo against the baseline.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Record post-treatment shade and photo"
        },
        {
          "detail": "Apply a fluoride varnish or desensitizing gel if the patient reports sensitivity or has a sensitivity history.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Apply desensitizing agent if indicated"
        },
        {
          "detail": "Advise avoiding dark-staining foods and drinks and tobacco for 24-48 hours, and that mild sensitivity is normal and should resolve within a few days.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-whitening instructions"
        },
        {
          "detail": "Log baseline and post shade, gel product and cycle count, barrier method, and any sensitivity or irritation observed, in the SOAP note.\n\nRecord: Whitening session note with shade before/after and cycle count",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the session"
        },
        {
          "detail": "In-office whitening session complete",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "In-office whitening session complete"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "In-office whitening — screening, isolation, gel application, sensitivity management — A patient is booked for a chairside whitening session.",
      "title": "In-office whitening — screening, isolation, gel application, sensitivity management",
      "trigger": "A patient is booked for a chairside whitening session",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "FDA/ADA whitening safety guidance (open)",
          "source": "FDA/ADA whitening safety guidance (open)"
        },
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=651",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — generic functional equivalent for the whitening/bleaching protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "DOCS/TECHNICAL_PROTOCOLS.md §4.1 reads: 'Shade selection before isolation (tooth dehydrates under rubber dam)...' (composite steps); §4.2 covers amalgam trituration, mercury hygiene, and the CA amalgam-separator mandate. Neither section, read in full, mentions whitening, bleaching agents, tray fabrication, gel application, or bleaching-related sensitivity/chemical-burn management. A repo-wide grep for 'whitening' and 'bleach' across DOCS/*.md returns no dedicated clinical-protocol document for in-office/take-home/internal whitening.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo restorative/whitening basis)",
              "url": null
            }
          },
          "source": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step."
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "rdir-018",
      "kind": "clinical",
      "materials": [
        "alginate or digital impression materials",
        "tray fabrication vacuum-form machine and tray material",
        "reservoir-relief wax",
        "take-home whitening gel (patient-appropriate concentration)",
        "gel syringes labeled for dispensing",
        "written instruction sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm signed consent covering expected shade change, sensitivity, the importance of following the prescribed wear schedule, and pregnancy/nursing deferral.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent including at-home use risks.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent including at-home use risks"
        },
        {
          "detail": "Take a shade-guide reading and reference photo before fabricating trays.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Record baseline shade and photo"
        },
        {
          "detail": "Take upper and lower impressions or a digital scan accurate enough to fabricate close-fitting whitening trays.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Take impressions or digital scans for tray fabrication"
        },
        {
          "detail": "Vacuum-form trays on the models and trim to a scalloped margin, adding a thin reservoir of relief wax on the facial surfaces of the teeth being whitened before forming, to hold gel against the tooth and off the gum margin.\n\nWhy: A reservoir keeps gel concentrated on enamel and reduces gel contact with gingiva, lowering irritation risk.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Fabricate trays with a gel reservoir",
          "why": "A reservoir keeps gel concentrated on enamel and reduces gel contact with gingiva, lowering irritation risk."
        },
        {
          "detail": "Seat the finished trays in the patient's mouth and confirm they seat fully, do not impinge on gum tissue, and do not rock.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Try in trays and check fit and margins"
        },
        {
          "detail": "Are the trays ready to dispense?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "ready",
              "label": "Fit and margins are correct — dispense"
            },
            {
              "goto": "s4",
              "id": "adjust",
              "label": "Trim or refabricate before dispensing"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Are the trays ready to dispense?"
        },
        {
          "detail": "Select the gel concentration and wear duration (daytime short-wear vs overnight lower-concentration) appropriate to the patient's sensitivity history and dispense labeled syringes.\n\nWhy: Overnight wear needs a lower peroxide concentration than a short daytime wear session to avoid excess soft-tissue and pulpal exposure.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Select and dispense gel concentration appropriate to the patient",
          "why": "Overnight wear needs a lower peroxide concentration than a short daytime wear session to avoid excess soft-tissue and pulpal exposure."
        },
        {
          "detail": "Provide a written instruction sheet: how much gel to place per tray well, wear duration, how to clean trays, what to do if gel contacts gum tissue, and to stop and call the office for persistent pain or blanched gum tissue.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Give written wear-schedule and hygiene instructions"
        },
        {
          "detail": "Schedule a follow-up visit or call within one to two weeks to assess shade progress and any sensitivity.\n\nWhy: A scheduled check catches sensitivity or poor adherence before the full course is wasted.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up check",
          "why": "A scheduled check catches sensitivity or poor adherence before the full course is wasted."
        },
        {
          "detail": "Log baseline shade, tray fit confirmation, gel concentration dispensed, and instructions given in the chart.\n\nRecord: Take-home whitening dispense note with gel concentration and wear schedule",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the dispense"
        },
        {
          "detail": "Take-home whitening trays dispensed",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Take-home whitening trays dispensed"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Take-home whitening — tray fabrication, dosage and instructions — A patient chose custom-tray whitening.",
      "title": "Take-home whitening — tray fabrication, dosage and instructions",
      "trigger": "A patient chose custom-tray whitening",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "FDA/ADA whitening safety guidance (open, extended to intracoronal bleaching context)",
          "source": "FDA/ADA whitening safety guidance (open, extended to intracoronal bleaching context)"
        },
        {
          "kind": "generic",
          "label": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — generic functional equivalent for the whitening/bleaching protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "DOCS/TECHNICAL_PROTOCOLS.md §4.1 reads: 'Shade selection before isolation (tooth dehydrates under rubber dam)...' (composite steps); §4.2 covers amalgam trituration, mercury hygiene, and the CA amalgam-separator mandate. Neither section, read in full, mentions whitening, bleaching agents, tray fabrication, gel application, or bleaching-related sensitivity/chemical-burn management. A repo-wide grep for 'whitening' and 'bleach' across DOCS/*.md returns no dedicated clinical-protocol document for in-office/take-home/internal whitening.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo restorative/whitening basis)",
              "url": null
            }
          },
          "source": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step."
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "rdir-019",
      "kind": "clinical",
      "materials": [
        "radiograph confirming adequate root canal filling",
        "isolation (dam preferred)",
        "sodium perborate or walking-bleach agent",
        "cervical seal barrier material (glass ionomer or similar)",
        "temporary restorative material",
        "cotton pellets"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Review a current radiograph confirming a well-condensed root canal filling with no periapical pathology, and confirm the tooth is asymptomatic, before starting internal bleaching.\n\nWhy: Internal bleaching should not begin on a tooth with an inadequate or symptomatic root canal treatment.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the root canal filling is adequate and asymptomatic",
          "why": "Internal bleaching should not begin on a tooth with an inadequate or symptomatic root canal treatment."
        },
        {
          "detail": "Confirm signed consent describing the walking-bleach process, the number of visits typically needed, and the rare but documented risk of external cervical resorption.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent including resorption risk.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent including resorption risk"
        },
        {
          "detail": "Take a shade-guide reading and reference photo of the discolored tooth against adjacent teeth.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Record baseline shade and photo"
        },
        {
          "detail": "Place isolation, preferably a rubber dam, before opening access to the pulp chamber.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the tooth"
        },
        {
          "detail": "Reopen access and remove root canal filling material to about 2mm below the cementoenamel junction (this depth is a conventional clinical figure, not attributed to a sourced public-domain guideline in this protocol; confirm the appropriate depth independently, since underfilling this step is the exact resorption-risk mechanism the cervical seal step below is guarding against), leaving the apical seal intact.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Remove gutta-percha to below the cervical margin"
        },
        {
          "detail": "Place a glass ionomer or similar barrier over the remaining root filling at the cervical level before any bleaching agent goes into the chamber.\n\nWhy: Without a cervical seal, bleaching agent can leak into the periodontal ligament and is the leading mechanism proposed for external cervical resorption after internal bleaching.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Place a cervical barrier seal",
          "why": "Without a cervical seal, bleaching agent can leak into the periodontal ligament and is the leading mechanism proposed for external cervical resorption after internal bleaching."
        },
        {
          "detail": "Visually and radiographically confirm the cervical barrier fully covers the canal orifice with no gaps before proceeding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm seal is complete before placing bleach.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm seal is complete before placing bleach"
        },
        {
          "detail": "Place the bleaching agent in the pulp chamber above the barrier and seal the access with a temporary restoration.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Place bleaching agent in the pulp chamber"
        },
        {
          "detail": "Schedule the patient to return in approximately one week to assess shade and, if needed, exchange the bleaching agent for another cycle.",
          "id": "s9",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 604800,
          "title": "Wait for the scheduled bleach-exchange visit"
        },
        {
          "detail": "Is the shade goal reached?",
          "forks": [
            {
              "goto": "s8",
              "id": "not-yet",
              "label": "Not yet — remove old agent, reseal, place fresh bleach"
            },
            {
              "advised": true,
              "goto": "s11",
              "id": "reached",
              "label": "Shade goal reached — remove bleach and restore"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the shade goal reached?"
        },
        {
          "detail": "Thoroughly clean residual bleaching agent from the chamber and place a bonded composite restoration to seal the access.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Remove residual bleach and place a definitive restoration"
        },
        {
          "detail": "Photograph the finished tooth next to the baseline reference photo for the chart.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Take a final comparison photo"
        },
        {
          "detail": "Log endodontic status confirmed, seal material and placement, number of bleach cycles, and final restoration in the SOAP note; note the resorption-monitoring recall.\n\nRecord: Internal bleach case note with cervical seal confirmation and cycle count",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the case"
        },
        {
          "detail": "Internal bleaching case complete",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Internal bleaching case complete"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Internal (walking) bleach of a discolored non-vital tooth — A single dark endodontically treated anterior tooth.",
      "title": "Internal (walking) bleach of a discolored non-vital tooth",
      "trigger": "A single dark endodontically treated anterior tooth",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.1 (in-repo composite basis)"
        },
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=651",
          "url_verified_at": "2026-09-14"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-patient",
      "id": "rdir-020",
      "kind": "clinical",
      "materials": [
        "shade guide",
        "isolation (dam or retraction)",
        "diagnostic mock-up or putty guide if used",
        "etch/bond materials",
        "layered composite kit",
        "fine finishing/polishing discs and strips",
        "articulating paper"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Review the specific change requested (close a gap, repair a chipped edge, reshape a tooth) and map it to which teeth need bonding versus enameloplasty (selective enamel reduction) only.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the specific esthetic goal and tooth-by-tooth plan"
        },
        {
          "detail": "Does the case need a diagnostic mock-up first?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "mockup",
              "label": "Multi-tooth or significant shape change — do a diagnostic mock-up first"
            },
            {
              "goto": "s3",
              "id": "no-mockup",
              "label": "Single small edge repair — proceed directly"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the case need a diagnostic mock-up first?"
        },
        {
          "detail": "Confirm signed consent covering the esthetic goal, that direct bonding is less wear-resistant than porcelain and may need future touch-up or repair, and any enamel reduction is irreversible.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent including durability limitations.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent including durability limitations"
        },
        {
          "detail": "Take a shade-guide reading and reference photo before treatment.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Take a baseline shade and photo"
        },
        {
          "detail": "Place a rubber dam or retraction isolation appropriate to the teeth being treated.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the field"
        },
        {
          "detail": "Is selective enamel reduction (enameloplasty) needed?",
          "forks": [
            {
              "goto": "s15",
              "id": "yes",
              "label": "Selectively reduce enamel to reshape or blend"
            },
            {
              "advised": true,
              "goto": "s7",
              "id": "no",
              "label": "No reduction needed — proceed to bonding"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is selective enamel reduction (enameloplasty) needed?"
        },
        {
          "detail": "Etch, rinse, dry to correct moisture level, apply bonding agent, and light-cure per the manufacturer's stated time.\n\nRecord: Bonding system used logged to the encounter",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Etch and bond per manufacturer protocol"
        },
        {
          "detail": "Layer and sculpt composite to close the gap, rebuild the edge, or reshape the tooth per the plan or mock-up, curing each increment.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Build and shape composite to the planned form"
        },
        {
          "detail": "Check the new contour in maximum intercuspation and lateral/protrusive excursions with articulating paper and adjust.\n\nWhy: New bonded contours can create premature contacts that chip the fresh composite if not adjusted immediately.\n\nRecord: Occlusion checked and adjusted, noted in the SOAP note",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Check occlusion and excursive contacts",
          "why": "New bonded contours can create premature contacts that chip the fresh composite if not adjusted immediately."
        },
        {
          "detail": "Contour and polish with a graduated sequence to a smooth, natural-looking finish matching adjacent teeth.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Finish and polish to match adjacent luster"
        },
        {
          "detail": "Photograph the finished result next to the baseline photo for the chart.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Take a final comparison photo"
        },
        {
          "detail": "If the patient has a history of clenching or grinding, discuss a nightguard to protect the new bonding from chipping.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss protective wear if the patient clenches or grinds"
        },
        {
          "detail": "Log which teeth were treated, whether enamel was reduced, materials used, and occlusion check result in the SOAP note.\n\nRecord: Bonding/contouring procedure note with before/after photos referenced",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Direct bonding and contouring complete",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Direct bonding and contouring complete"
        },
        {
          "detail": "Reduce enamel conservatively with a fine diamond or abrasive strip to reshape edges or blend transitions, staying within enamel.\n\nWhy: Reduction limited to enamel avoids exposing dentin and keeps the procedure reversible in the sense of not committing the tooth to future restoration.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Selectively reduce enamel",
          "why": "Reduction limited to enamel avoids exposing dentin and keeps the procedure reversible in the sense of not committing the tooth to future restoration."
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Direct composite bonding (diastema closure, edge repair, reshaping) and enameloplasty — A patient wants a minimally invasive esthetic change of anterior teeth.",
      "title": "Direct composite bonding (diastema closure, edge repair, reshaping) and enameloplasty",
      "trigger": "A patient wants a minimally invasive esthetic change of anterior teeth",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "FDA/ADA whitening safety guidance (open) — sensitivity and soft-tissue irritation are documented, expected, and self-resolving adverse effects",
          "source": "FDA/ADA whitening safety guidance (open) — sensitivity and soft-tissue irritation are documented, expected, and self-resolving adverse effects"
        },
        {
          "kind": "generic",
          "label": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — generic functional equivalent for the whitening/bleaching protocols"
          },
          "repaired": {
            "action": "generic",
            "evidence": "DOCS/TECHNICAL_PROTOCOLS.md §4.1 reads: 'Shade selection before isolation (tooth dehydrates under rubber dam)...' (composite steps); §4.2 covers amalgam trituration, mercury hygiene, and the CA amalgam-separator mandate. Neither section, read in full, mentions whitening, bleaching agents, tray fabrication, gel application, or bleaching-related sensitivity/chemical-burn management. A repo-wide grep for 'whitening' and 'bleach' across DOCS/*.md returns no dedicated clinical-protocol document for in-office/take-home/internal whitening.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo restorative/whitening basis)",
              "url": null
            }
          },
          "source": "No authority found. DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 ('Composite Resin Restoration (Direct)' and 'Amalgam Restoration') is a direct-filling technique protocol and contains no whitening, bleaching, gel-application, or sensitivity-management content — Practice policy — no published authority governs this step."
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rdir-021",
      "kind": "clinical",
      "materials": [
        "desensitizing gel or fluoride varnish",
        "saline or water for rinsing",
        "topical soothing agent for gum tissue (e.g. vitamin E oil or petroleum jelly per office protocol)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "What is the patient reporting?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "sensitivity",
              "label": "Tooth sensitivity or zinging pain, no visible tissue damage"
            },
            {
              "goto": "s5",
              "id": "burn",
              "label": "Visible white or blanched gum spot, or ongoing gum pain"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "What is the patient reporting?"
        },
        {
          "detail": "Advise the patient that mild sensitivity is a common, expected, self-limiting effect of whitening; recommend a sensitivity toothpaste and avoiding further whitening for a day or two, and to call back if pain worsens or persists beyond a few days.\n\nWhy: Most whitening-related tooth sensitivity resolves on its own within days and does not need an in-office visit.",
          "id": "s2",
          "kind": "step",
          "role": "hygienist",
          "title": "Give phone advice for tooth sensitivity",
          "why": "Most whitening-related tooth sensitivity resolves on its own within days and does not need an in-office visit."
        },
        {
          "detail": "Log the reported symptom, advice given, and any callback instruction in the chart.\n\nRecord: Phone triage note for whitening sensitivity",
          "id": "s3",
          "kind": "step",
          "role": "hygienist",
          "title": "Log the phone call"
        },
        {
          "detail": "Whitening sensitivity or burn incident closed",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Whitening sensitivity or burn incident closed"
        },
        {
          "detail": "Offer to see the patient the same day or as soon as possible when a visible gum lesion or persistent pain is reported.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer a same-day or next-available visit"
        },
        {
          "detail": "Examine the gum tissue for the extent and depth of the blanching or lesion, and photograph it for the chart.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Examine the affected tissue"
        },
        {
          "detail": "The treating dentist personally confirms the severity grading (superficial vs significant) before an assistant or hygienist proceeds with any soothing treatment or escalation call.\n\nWhy: Treatment choice for a chemical burn depends on a clinical judgment call that must be made by the licensed dentist, not delegated on the phone description alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on severity before treatment is chosen.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on severity before treatment is chosen",
          "why": "Treatment choice for a chemical burn depends on a clinical judgment call that must be made by the licensed dentist, not delegated on the phone description alone."
        },
        {
          "detail": "How severe is the tissue reaction?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "mild",
              "label": "Superficial blanching, no ulceration — soothe and monitor"
            },
            {
              "goto": "s12",
              "id": "significant",
              "label": "Ulceration, significant pain, or spreading beyond the gel-contact area"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "How severe is the tissue reaction?"
        },
        {
          "detail": "Apply a topical soothing agent to the affected tissue and instruct the patient to rinse with warm saline, avoid spicy or acidic foods, and expect healing within a few days.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Apply a soothing agent and give home-care instructions"
        },
        {
          "detail": "Log the affected area, severity, treatment given, photo reference, and follow-up plan in the SOAP note.\n\nRecord: Whitening-related incident note with photo reference",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the incident and treatment"
        },
        {
          "detail": "Call the patient within a few days to confirm the sensitivity or gum irritation has resolved as expected.",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Place a follow-up call to confirm resolution"
        },
        {
          "detail": "Provide symptomatic relief and consider referral to an oral medicine or periodontal specialist if ulceration is significant, spreading, or not improving.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Manage or refer for a more significant chemical burn"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Whitening sensitivity or gingival chemical burn response — A patient reports zinging pain or a white blanched gum spot after whitening.",
      "title": "Whitening sensitivity or gingival chemical burn response",
      "trigger": "A patient reports zinging pain or a white blanched gum spot after whitening",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "State dental board scope-of-practice determination for facial esthetic procedures performed by a licensed dentist (varies by state; verify current board rule before offering)",
          "source": "State dental board scope-of-practice determination for facial esthetic procedures performed by a licensed dentist (varies by state; verify current board rule before offering)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication and Bloodborne Pathogens Standard (29 CFR 1910.1030) for injection sharps handling",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication and Bloodborne Pathogens Standard (29 CFR 1910.1030) for injection sharps handling",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2023-title29-vol6/pdf/CFR-2023-title29-vol6-sec1910-1030.pdf",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "statute",
          "label": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "source": "CA B&P §651 / FTC advertising rules for before-after image claims",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=651",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "Neuromodulator and dermal-filler injections: scope, training and consent — generic functional equivalent (state dental-board scope-of-practice + informed-consent standard for aesthetic procedures)",
          "repaired": {
            "action": "generic",
            "evidence": "Direct read of DOCS/TECHNICAL_PROTOCOLS.md §4.1 (Composite Resin Restoration) and §4.2 (Amalgam Restoration): both are step-by-step filling-placement procedures with no reference to injectables, aesthetic-medicine scope, training hours, or consent content.",
            "ticket": "PROT-017",
            "was": {
              "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 (in-repo restorative/cosmetic basis, generic functional equivalent for scope-and-consent checklist)",
              "url": null
            }
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.1-4.2 are composite/amalgam restorative placement steps and do not address injectable scope of practice, training, or consent; generic functional equivalent per state dental-board guidance on whether/how a general dentist may add neuromodulator/filler services"
        }
      ],
      "class": "direct-restorative-cosmetic",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "rdir-022",
      "kind": "clinical",
      "materials": [
        "neuromodulator or dermal filler product (per manufacturer instructions for use)",
        "sharps disposal container",
        "emergency medication kit including anaphylaxis treatment",
        "consent and medical history form",
        "photo documentation setup"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Before the practice offers or the dentist performs neuromodulator or filler injections, confirm the current state dental board rule permits it for a licensed dentist and confirm the treating dentist holds the required training/certification on file.\n\nWhy: Facial injectable scope for dentists varies by state and changes; performing outside authorized scope is a licensure risk independent of clinical outcome.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm state board scope-of-practice and training before any injection is offered.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Confirm state board scope-of-practice and training before any injection is offered",
          "why": "Facial injectable scope for dentists varies by state and changes; performing outside authorized scope is a licensure risk independent of clinical outcome."
        },
        {
          "detail": "Screen for pregnancy/nursing, bleeding disorders or anticoagulant use, known allergies to the product or its components, active infection at the injection site, and neuromuscular disorders.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Take a targeted medical history"
        },
        {
          "detail": "Any contraindication identified?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clear",
              "label": "No contraindication — proceed to consent"
            },
            {
              "goto": "s15",
              "id": "contraindicated",
              "label": "Contraindication present — defer or refer"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Any contraindication identified?"
        },
        {
          "detail": "Confirm signed consent covering expected results, duration, injection-site risks (bruising, asymmetry, rare vascular occlusion), and that this is an elective esthetic procedure, before any product is drawn up.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent including risks and this is not a medical necessity procedure.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent including risks and this is not a medical necessity procedure"
        },
        {
          "detail": "Photograph the treatment area at rest and in relevant expressions (e.g. frown, smile) before injecting.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Take baseline photos of the treatment area"
        },
        {
          "detail": "Mark planned injection points and confirm the product, dilution, and dose per site against the treatment plan before drawing up.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Mark injection sites and confirm dosing plan"
        },
        {
          "detail": "Confirm the anaphylaxis/emergency medication kit is in the room and within expiration before the first injection of the session.\n\nWhy: Injectable products carry a low but real allergic and vascular-event risk that needs an immediate response capability on hand.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm emergency medication kit is present and unexpired.",
            "role": "assistant / office manager",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "assistant",
          "title": "Confirm emergency medication kit is present and unexpired",
          "why": "Injectable products carry a low but real allergic and vascular-event risk that needs an immediate response capability on hand."
        },
        {
          "detail": "Administer the product at the marked sites using aseptic technique, aspirating per product instructions where applicable, and monitor the patient throughout.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Administer the injections"
        },
        {
          "detail": "Have the patient remain in the office and observe for signs of an allergic or vascular reaction before discharge.",
          "id": "s9",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 900,
          "title": "Monitor the patient for an immediate reaction"
        },
        {
          "detail": "Any adverse reaction observed?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "none",
              "label": "No reaction — proceed to discharge"
            },
            {
              "goto": "s16",
              "id": "reaction",
              "label": "Reaction observed — treat and escalate"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Any adverse reaction observed?"
        },
        {
          "detail": "Photograph the treatment area immediately after injection for the chart, matching the baseline angles.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Take post-injection photos"
        },
        {
          "detail": "Advise avoiding rubbing the treated area, strenuous exercise, and lying flat for the period specified by the product instructions; explain expected onset timeline and when to call with concerns.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-injection instructions"
        },
        {
          "detail": "Log product name, lot number, dose per site, sites treated, patient tolerance, and any reaction and its management in the SOAP note.\n\nRecord: Injectable session note with product/lot/dose and photo reference",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the session"
        },
        {
          "detail": "Injectable session complete",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Injectable session complete"
        },
        {
          "detail": "Explain to the patient why treatment is deferred or referred (e.g. to their physician for anticoagulant management, or to a specialist), and document the reason.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Defer treatment or refer out"
        },
        {
          "detail": "Administer epinephrine intramuscularly immediately per the emergency kit's instructions, then call 911; continue supportive care per the kit's protocol until EMS arrives.",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Treat the reaction and call 911 if severe"
        }
      ],
      "subclass": "direct-restorative-and-cosmetic-dentistry",
      "summary": "Neuromodulator and dermal-filler injections: scope, training and consent — A patient asks the dentist for facial injectables, or the practice adds them.",
      "title": "Neuromodulator and dermal-filler injections: scope, training and consent",
      "trigger": "A patient asks the dentist for facial injectables, or the practice adds them",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (cements, etchants SDS)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (cements, etchants SDS)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-patient",
      "id": "rind-001",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "shade guide",
        "depth-cutting burs",
        "reduction-verification putty or matrix",
        "diamond burs (coarse and fine)",
        "retraction cord or gingival management material",
        "temporary crown material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Verify the tooth number, planned restorative material (zirconia, lithium disilicate, PFM, full metal), and target shade against the treatment plan and radiograph before anesthetic is given.\n\nWhy: Wrong-tooth errors and material mismatches are caught cheaply before anything irreversible happens.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm tooth, material and shade before starting",
          "why": "Wrong-tooth errors and material mismatches are caught cheaply before anything irreversible happens."
        },
        {
          "detail": "Confirm a signed consent for crown preparation is in the chart, including material choice and the possibility of a provisional between visits, before administering anesthetic.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent on file before treatment.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent on file before treatment"
        },
        {
          "detail": "Select the target shade against adjacent and contralateral teeth and record it in the chart before the tooth is dried or isolated.\n\nWhy: A dehydrated, isolated tooth appears lighter than its true shade, making mid-procedure shade selection unreliable.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Select and record shade before isolation",
          "why": "A dehydrated, isolated tooth appears lighter than its true shade, making mid-procedure shade selection unreliable."
        },
        {
          "detail": "Administer local anesthetic appropriate to the tooth and confirm profound anesthesia before proceeding.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Place depth-orientation grooves on the occlusal/incisal and axial surfaces at the reduction depth appropriate to the selected material.\n\nWhy: Depth-orientation grooves give a physical checkpoint so reduction does not fall short in one area while over-reducing another.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Place orientation depth cuts",
          "why": "Depth-orientation grooves give a physical checkpoint so reduction does not fall short in one area while over-reducing another."
        },
        {
          "detail": "Reduce the occlusal/incisal and axial surfaces to the depth cuts, maintaining the planned path of insertion and a continuous finish line.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Complete gross reduction to the depth cuts"
        },
        {
          "detail": "Verify reduction against the target before finishing margins",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "putty",
              "label": "Check with a pre-op putty index sectioned over the prep"
            },
            {
              "goto": "s8",
              "id": "visual",
              "label": "Visual/explorer check only"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Verify reduction against the target before finishing margins"
        },
        {
          "detail": "Refine the margin to a continuous, smooth finish line of the type appropriate to the material (chamfer, shoulder, or feather-edge), free of undercuts.\n\nWhy: An inconsistent or undercut margin causes a poor lab fit and an open margin at cementation.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Finish the margin design",
          "why": "An inconsistent or undercut margin causes a poor lab fit and an open margin at cementation."
        },
        {
          "detail": "Round internal line angles and visually confirm the preparation has a single path of insertion with no undercuts.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Round internal line angles and confirm draw"
        },
        {
          "detail": "Is dentin exposure deep or was there any pulpal proximity concern?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "normal",
              "label": "Normal depth — proceed to impression/scan workflow"
            },
            {
              "goto": "s14",
              "id": "deep",
              "label": "Deep dentin exposure near pulp — place a protective liner first"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Is dentin exposure deep or was there any pulpal proximity concern?"
        },
        {
          "detail": "Preparation is complete; proceed to the gingival retraction/hemostasis protocol (rind-005) and then impression (rind-006) or a digital scan.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to gingival retraction and impression"
        },
        {
          "detail": "Log tooth, material selected, shade, margin design, and any liner placed in the SOAP note.\n\nRecord: Procedure note with material, shade and margin design",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document the preparation"
        },
        {
          "detail": "Preparation complete, ready for retraction and impression",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Preparation complete, ready for retraction and impression"
        },
        {
          "detail": "Place a calcium hydroxide or bioceramic liner over any area of deep dentin exposure before proceeding to impression.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Place a protective liner over deep dentin"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Full-coverage crown preparation with reduction checkpoints — A tooth is planned for a crown; anesthesia is complete and the shade is taken.",
      "title": "Full-coverage crown preparation with reduction checkpoints",
      "trigger": "A tooth is planned for a crown; anesthesia is complete and the shade is taken",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, generalized to partial coverage)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, generalized to partial coverage)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (cements, etchants SDS)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (cements, etchants SDS)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 50,
      "frequency": "per-patient",
      "id": "rind-002",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "shade guide",
        "diamond burs for cavity-form and cuspal reduction",
        "old restorative/caries removal instruments",
        "retraction cord",
        "temporary material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Verify the tooth number, extent of the existing restoration or fracture, and target shade against the treatment plan and radiograph.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm tooth, existing restoration and shade"
        },
        {
          "detail": "Confirm a signed consent for onlay/inlay preparation is in the chart, including the possibility the plan converts to a full crown intra-operatively.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent on file before treatment.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent on file before treatment"
        },
        {
          "detail": "Administer local anesthetic appropriate to the tooth and confirm profound anesthesia before proceeding.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Remove the failing restoration and any caries, exposing sound tooth structure and the extent of the defect.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Remove existing restoration and caries"
        },
        {
          "detail": "Assess how much cusp structure remains sound",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "onlay",
              "label": "One or more cusps are thin/undermined — cover them (onlay)"
            },
            {
              "goto": "s7",
              "id": "inlay",
              "label": "Cusps are sound and thick — no coverage needed (inlay)"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess how much cusp structure remains sound"
        },
        {
          "detail": "Reduce the compromised cusp(s) by the depth appropriate to the material to allow adequate coverage thickness.\n\nWhy: An unreduced thin cusp left uncovered under occlusal load is the leading cause of onlay/inlay-adjacent cusp fracture.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Reduce and cover the compromised cusp(s)",
          "why": "An unreduced thin cusp left uncovered under occlusal load is the leading cause of onlay/inlay-adjacent cusp fracture."
        },
        {
          "detail": "Shape internal walls with a slight outward divergence and rounded internal line angles to allow a single path of insertion for the indirect restoration.\n\nWhy: Undercuts prevent the milled or cast restoration from seating.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Refine the cavity form with divergent walls",
          "why": "Undercuts prevent the milled or cast restoration from seating."
        },
        {
          "detail": "Finish all margins to a smooth, continuous line free of unsupported enamel.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Finish proximal and cavosurface margins"
        },
        {
          "detail": "Preparation is complete; proceed to gingival retraction/hemostasis (rind-005) if margins are subgingival, then impression (rind-006) or digital scan.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to retraction and impression"
        },
        {
          "detail": "Log tooth, final design (inlay vs. onlay) and reasoning, material, and shade in the SOAP note.\n\nRecord: Procedure note with inlay/onlay decision and material",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the preparation"
        },
        {
          "detail": "Preparation complete, ready for retraction and impression",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Preparation complete, ready for retraction and impression"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Partial-coverage onlay or inlay preparation — A cusp fracture or large restoration needs cusp coverage but not a full crown.",
      "title": "Partial-coverage onlay or inlay preparation",
      "trigger": "A cusp fracture or large restoration needs cusp coverage but not a full crown",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, generalized to veneer preparation)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, generalized to veneer preparation)"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 75,
      "frequency": "per-patient",
      "id": "rind-003",
      "kind": "clinical",
      "materials": [
        "local anesthetic (optional, minimal-prep cases may not need it)",
        "diagnostic mock-up / silicone reduction guide",
        "depth-cutting burs for veneer preparation",
        "shade guide and photography setup",
        "provisional veneer material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the diagnostic mock-up (wax-up or direct mock-up) has been reviewed and approved by the patient, and that it defines the planned tooth reduction.\n\nWhy: The mock-up is what the preparation depth is measured against, not a free-hand estimate.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Review the approved mock-up with the patient",
          "why": "The mock-up is what the preparation depth is measured against, not a free-hand estimate."
        },
        {
          "detail": "Confirm signed consent covers the case, expected outcome shown in the mock-up, and the limitations of porcelain veneers, before preparation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent covering esthetic expectations.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent covering esthetic expectations"
        },
        {
          "detail": "Photograph the pre-op dentition and select the baseline shade before any anesthetic or drying.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Take baseline shade and reference photos"
        },
        {
          "detail": "Seat the silicone index made from the approved mock-up to guide facial and incisal reduction depth.\n\nWhy: A reduction guide keeps preparation conservative and consistent with the approved design rather than over-reducing.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the silicone reduction guide",
          "why": "A reduction guide keeps preparation conservative and consistent with the approved design rather than over-reducing."
        },
        {
          "detail": "Is anesthesia needed for this prep depth?",
          "forks": [
            {
              "goto": "s7",
              "id": "minimal",
              "label": "Minimal/no-prep design — proceed without anesthesia"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "conventional",
              "label": "Conventional reduction into dentin — administer anesthesia first"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is anesthesia needed for this prep depth?"
        },
        {
          "detail": "Administer local anesthetic and confirm profound anesthesia before proceeding.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia"
        },
        {
          "detail": "Reduce the facial surface to the depth shown through the reduction guide's windows, maintaining natural surface contour.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Reduce the facial surface through the guide windows"
        },
        {
          "detail": "Extend reduction to the incisal edge and interproximal contacts per the approved design, keeping margins supragingival where esthetics allow.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Refine incisal and proximal margins"
        },
        {
          "detail": "Smooth the finish line to a continuous margin free of sharp transitions.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Smooth and finish all margins"
        },
        {
          "detail": "Preparation is complete; proceed to impression (rind-006) or digital scan, then provisional fabrication (rind-007) using the approved mock-up shape.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to impression and provisional fabrication"
        },
        {
          "detail": "Send the case to the lab with the shade selection, baseline photos, and the mock-up or its digital equivalent as the shape reference.\n\nRecord: Lab prescription with shade, photos and mock-up reference",
          "id": "s11",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send lab prescription with shade and photos"
        },
        {
          "detail": "Log tooth numbers, prep style (minimal vs. conventional), shade, and mock-up reference in the SOAP note.\n\nRecord: Procedure note with prep style, shade and mock-up reference",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Veneer preparation complete, case sent to lab",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Veneer preparation complete, case sent to lab"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Porcelain veneer preparation, provisional and shade communication — An anterior esthetic case with an approved mock-up and consent.",
      "title": "Porcelain veneer preparation, provisional and shade communication",
      "trigger": "An anterior esthetic case with an approved mock-up and consent",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, generalized to multi-abutment bridge work)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, generalized to multi-abutment bridge work)"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "per-patient",
      "id": "rind-004",
      "kind": "clinical",
      "materials": [
        "local anesthetic",
        "shade guide",
        "depth-cutting and reduction burs",
        "surveying instrument or visual parallel guide",
        "retraction cord",
        "long-span provisional material"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Verify the abutment tooth numbers, the pontic span, and the planned material against the treatment plan and radiographs.\n\nWhy: Bridge design errors are far more costly to correct after preparation than a full crown, since two or more teeth are committed.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm abutment teeth, pontic span and material",
          "why": "Bridge design errors are far more costly to correct after preparation than a full crown, since two or more teeth are committed."
        },
        {
          "detail": "Confirm the chart shows implant and removable-partial-denture alternatives were discussed and the patient chose a fixed bridge.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm alternatives were discussed"
        },
        {
          "detail": "Confirm a signed consent for bridge preparation is in the chart, naming the abutment teeth, pontic span, material, and that a provisional bridge will be worn between visits.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent on file before treatment.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent on file before treatment"
        },
        {
          "detail": "Select the target shade against adjacent and contralateral teeth and record it in the chart before drying or isolating the abutments.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Select and record shade before isolation"
        },
        {
          "detail": "Administer local anesthetic covering all abutment teeth and confirm profound anesthesia before proceeding.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Administer local anesthesia for all abutments"
        },
        {
          "detail": "Prepare the first abutment following full-coverage crown reduction and margin standards (see rind-001).",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare the first abutment to full-coverage standards"
        },
        {
          "detail": "Prepare each additional abutment to the same reduction and margin standard as the first.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Prepare remaining abutment(s) to the same reduction standard"
        },
        {
          "detail": "Verify a single common path of insertion across all abutments",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "verified",
              "label": "Path confirmed with a surveyor or visual parallel check"
            },
            {
              "goto": "s14",
              "id": "conflict",
              "label": "Undercut or divergent path found between abutments"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Verify a single common path of insertion across all abutments"
        },
        {
          "detail": "Finish all abutment margins to a continuous, smooth line free of undercuts.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Finish and smooth all margins"
        },
        {
          "detail": "All abutments are prepared with a verified common path of insertion; proceed to gingival retraction (rind-005) and impression (rind-006) or digital scan capturing all abutments in one impression.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to retraction and impression"
        },
        {
          "detail": "Send the case to the lab specifying abutment teeth, pontic design, material, and shade.\n\nRecord: Lab prescription with bridge design and shade",
          "id": "s11",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send lab prescription with bridge design"
        },
        {
          "detail": "Log abutment teeth, pontic span, material, shade, and path-of-insertion verification in the SOAP note.\n\nRecord: Procedure note with abutments, pontic design and path verification",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Bridge preparation complete, case sent to lab",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Bridge preparation complete, case sent to lab"
        },
        {
          "detail": "Reduce the axial wall of the conflicting abutment further to eliminate the undercut and re-verify the common path.\n\nWhy: Two or more abutments prepared with divergent paths cannot seat as one rigid bridge, and this is unfixable in the lab.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Adjust the conflicting abutment to remove the undercut",
          "why": "Two or more abutments prepared with divergent paths cannot seat as one rigid bridge, and this is unfixable in the lab."
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Fixed bridge preparation with a common path of insertion — A missing tooth with suitable abutments where the patient chose a fixed bridge.",
      "title": "Fixed bridge preparation with a common path of insertion",
      "trigger": "A missing tooth with suitable abutments where the patient chose a fixed bridge",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, retraction dependency)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, retraction dependency)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 Hazard Communication (hemostatic agent SDS)",
          "source": "OSHA 29 CFR 1910.1200 Hazard Communication (hemostatic agent SDS)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "rind-005",
      "kind": "clinical",
      "materials": [
        "retraction cord (single or double cord technique)",
        "hemostatic agent",
        "cord-packing instrument",
        "gauze",
        "alternative retraction material or paste system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the signed consent for the crown/veneer/bridge procedure this step belongs to is already in the chart before manipulating tissue.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent for the overall procedure is on file.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent for the overall procedure is on file"
        },
        {
          "detail": "Confirm the margin location relative to the gingiva and check for any bleeding or inflamed tissue before selecting a retraction method.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Assess margin location and tissue condition"
        },
        {
          "detail": "Select the retraction technique",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "double-cord",
              "label": "Double cord technique (fine cord placed first, larger cord second)"
            },
            {
              "goto": "s4",
              "id": "single-cord",
              "label": "Single cord technique"
            },
            {
              "goto": "s13",
              "id": "cordless",
              "label": "Cordless paste/expansion system"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Select the retraction technique"
        },
        {
          "detail": "Pack the fine cord gently into the sulcus around the entire margin using a packing instrument, without excessive apical force.\n\nWhy: Excessive force lacerates the epithelial attachment and causes bleeding that then contaminates the impression.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Place the first (fine) cord at the sulcus",
          "why": "Excessive force lacerates the epithelial attachment and causes bleeding that then contaminates the impression."
        },
        {
          "detail": "Is bleeding present?",
          "forks": [
            {
              "goto": "s14",
              "id": "yes",
              "label": "Yes — apply a hemostatic agent"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "no",
              "label": "No — proceed to second cord or dwell"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is bleeding present?"
        },
        {
          "detail": "Place a second, larger cord?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes",
              "label": "Yes — double cord technique"
            },
            {
              "goto": "s8",
              "id": "no",
              "label": "No — single cord is sufficient"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Place a second, larger cord?"
        },
        {
          "detail": "Pack a larger cord over the first for the working dwell time, leaving the first cord in place to protect the sulcus.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Place the second cord"
        },
        {
          "detail": "Leave cord(s) in place for a default dwell time of 5 minutes (products vary in their manufacturer-recommended range, generally 4-8 minutes; use the specific product's stated time if it differs) to achieve tissue displacement and hemostasis.",
          "id": "s8",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 300,
          "title": "Allow cord dwell time"
        },
        {
          "detail": "Remove the top cord immediately before syringing impression material, leaving the bottom cord in place if double cord technique was used and no bleeding is present, or remove entirely if single cord.\n\nWhy: Leaving the fine bottom cord in place keeps the sulcus open for material flow while the tissue stays displaced.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Remove the top cord (double cord) or the single cord just before impression",
          "why": "Leaving the fine bottom cord in place keeps the sulcus open for material flow while the tissue stays displaced."
        },
        {
          "detail": "Visually confirm the sulcus is open, dry, and free of bleeding before proceeding to the impression or scan.\n\nRecord: Retraction technique and hemostasis result logged to the encounter",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm dry, retracted sulcus before impression"
        },
        {
          "detail": "Sulcus is retracted and dry; proceed immediately to impression (rind-006) or digital scan before tissue rebounds.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to impression"
        },
        {
          "detail": "Retraction complete, ready for impression",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Retraction complete, ready for impression"
        },
        {
          "detail": "Apply the cordless paste or expansion system per manufacturer instructions and allow the stated dwell time.",
          "id": "s13",
          "kind": "step",
          "role": "assistant",
          "title": "Apply cordless retraction material"
        },
        {
          "detail": "Apply the hemostatic agent per manufacturer instructions, allow it to act, then rinse and re-check for bleeding before continuing.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Apply hemostatic agent and re-check"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Gingival retraction and hemostasis before impression — The preparation margin is at or below the gingiva.",
      "title": "Gingival retraction and hemostasis before impression",
      "trigger": "The preparation margin is at or below the gingiva",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC guidance on disinfecting impressions and prostheses",
          "source": "CDC guidance on disinfecting impressions and prostheses",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, impression dependency)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, impression dependency)"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "rind-006",
      "kind": "clinical",
      "materials": [
        "impression tray (stock or custom)",
        "light-body and heavy/putty-body elastomeric impression material",
        "impression gun/mixing tips",
        "bite registration material",
        "disinfectant spray approved for impressions",
        "sealable bag for transport"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the signed consent for the crown/veneer/bridge procedure this impression belongs to is already in the chart.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent for the overall procedure is on file.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent for the overall procedure is on file"
        },
        {
          "detail": "Select a stock or custom tray that fully seats over the prepared tooth or bridge span with adequate material thickness in all directions.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Select an appropriately sized tray"
        },
        {
          "detail": "Syringe light-body impression material directly around the prepared tooth/teeth, into the sulcus, before the tray is seated.\n\nWhy: Light-body material captures fine detail at the margin that heavy tray material alone cannot reach.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Syringe light-body material around the preparation",
          "why": "Light-body material captures fine detail at the margin that heavy tray material alone cannot reach."
        },
        {
          "detail": "Load the tray with heavy-body or putty material while the light-body material is still workable.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Load heavy-body or putty material into the tray"
        },
        {
          "detail": "Seat the loaded tray over the prepared arch with firm, even pressure and hold it still through the material's full set time.\n\nWhy: Tray movement during set produces a distorted impression that fits nothing accurately.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the tray and hold until set",
          "why": "Tray movement during set produces a distorted impression that fits nothing accurately."
        },
        {
          "detail": "Wait the manufacturer-stated set time for the impression material before removing the tray.",
          "id": "s6",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 240,
          "title": "Wait for full material set"
        },
        {
          "detail": "Remove the tray with one firm, even pull along the path of insertion, avoiding a rocking motion.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Remove the tray with a single firm pull"
        },
        {
          "detail": "Inspect the impression for voids, pulls or tears at the margin",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "acceptable",
              "label": "Margin is fully captured, no voids or tears"
            },
            {
              "goto": "s15",
              "id": "redo",
              "label": "Margin is missing, torn or has a void — redo"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Inspect the impression for voids, pulls or tears at the margin"
        },
        {
          "detail": "Take a bite registration in the patient's habitual occlusion, or verify an existing digital/stone bite is current.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Take a bite registration"
        },
        {
          "detail": "Take an impression or confirm a current scan of the opposing arch for the lab to mount the case correctly.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Take or confirm the opposing arch impression or scan"
        },
        {
          "detail": "Rinse debris from each impression, spray or immerse with an approved disinfectant, and hold the manufacturer-stated contact time before bagging for the lab.\n\nWhy: An unrinsed or under-disinfected impression is a documented cross-contamination route between patient and lab.\n\nRecord: Disinfectant product and contact time logged to the encounter",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect all impressions before transport",
          "why": "An unrinsed or under-disinfected impression is a documented cross-contamination route between patient and lab."
        },
        {
          "detail": "Bag the disinfected impressions and bite registration with the lab prescription and case identifier, ready for pickup or courier.\n\nRecord: Lab shipment record with case identifier",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Package and log the case for lab pickup"
        },
        {
          "detail": "Log impression material used, verification result, and lab shipment status in the chart.\n\nRecord: Procedure note with impression outcome",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Impression complete and sent to lab",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Impression complete and sent to lab"
        },
        {
          "detail": "Re-check the sulcus is dry and retracted (see rind-005), reload the tray, and retake the impression.",
          "id": "s15",
          "kind": "step",
          "role": "assistant",
          "title": "Re-prepare tray/material and retake the impression"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Conventional elastomeric impression, verification and disinfection — Preparation is complete and no intraoral scanner is being used.",
      "title": "Conventional elastomeric impression, verification and disinfection",
      "trigger": "Preparation is complete and no intraoral scanner is being used",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, provisional dependency)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, provisional dependency)"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for cements (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for cements (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "rind-007",
      "kind": "clinical",
      "materials": [
        "pre-op matrix or shell crown form",
        "provisional (bis-acryl or acrylic) material",
        "temporary cement (non-eugenol if a bonded final restoration is planned)",
        "articulating paper",
        "finishing/polishing instruments"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the signed consent for the crown/veneer/bridge procedure this provisional belongs to is already in the chart.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent for the overall procedure is on file.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent for the overall procedure is on file"
        },
        {
          "detail": "Select provisional fabrication technique",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "matrix",
              "label": "Pre-op putty matrix filled with provisional material"
            },
            {
              "goto": "s14",
              "id": "shell",
              "label": "Pre-formed shell crown/bridge form"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Select provisional fabrication technique"
        },
        {
          "detail": "Fill the putty matrix made before preparation with provisional material and seat it over the prepared tooth/teeth.\n\nWhy: A matrix taken before any tooth structure was removed reproduces the original anatomy and contacts closely.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Load the pre-op matrix with provisional material",
          "why": "A matrix taken before any tooth structure was removed reproduces the original anatomy and contacts closely."
        },
        {
          "detail": "Allow the provisional material to reach initial set, remove from the mouth, and remove excess/flash before final adjustment.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Allow set, then remove and inspect"
        },
        {
          "detail": "Trim the provisional margins to match the prepared tooth's finish line and smooth all edges.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Trim and smooth margins"
        },
        {
          "detail": "Have the patient bite on articulating paper in maximum intercuspation and lateral excursions; adjust and polish any high spots.\n\nWhy: A high provisional causes discomfort or fracture and can shift the bite before the final restoration is even tried in.\n\nRecord: Occlusion checked and adjusted, noted in the SOAP note",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Check and adjust occlusion",
          "why": "A high provisional causes discomfort or fracture and can shift the bite before the final restoration is even tried in."
        },
        {
          "detail": "Polish the provisional surface smooth to reduce plaque retention and improve patient comfort.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Polish the provisional"
        },
        {
          "detail": "Select temporary cement based on the planned final material",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "non-eugenol",
              "label": "Non-eugenol temporary cement (final restoration will be resin-bonded)"
            },
            {
              "goto": "s9",
              "id": "eugenol",
              "label": "Eugenol-containing temporary cement (final restoration will be conventionally cemented)"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Select temporary cement based on the planned final material"
        },
        {
          "detail": "Seat the provisional with the selected temporary cement and remove all excess cement from margins and interproximally, checking with floss.\n\nWhy: Retained subgingival temporary cement is a leading cause of localized inflammation that is mistaken for a failing final restoration.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Cement the provisional and remove excess",
          "why": "Retained subgingival temporary cement is a leading cause of localized inflammation that is mistaken for a failing final restoration."
        },
        {
          "detail": "Explain to avoid sticky or hard foods, floss carefully by sliding rather than lifting out, and to call if the provisional comes off before the next visit.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Give provisional care instructions"
        },
        {
          "detail": "Schedule the patient for the try-in and delivery visit once the lab case is expected back.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the try-in/delivery visit"
        },
        {
          "detail": "Log provisional material, cement used, and occlusion check result in the SOAP note.\n\nRecord: Procedure note with provisional material and cement",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Document the procedure"
        },
        {
          "detail": "Provisional delivered, next visit scheduled",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Provisional delivered, next visit scheduled"
        },
        {
          "detail": "Select a shell form sized to the prepared tooth and trim the margins to approximate fit before filling with provisional material.",
          "id": "s14",
          "kind": "step",
          "role": "assistant",
          "title": "Select and trim a shell crown form"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Provisional restoration fabrication, occlusion check and cementation — The impression or scan is done and the tooth must be protected until delivery.",
      "title": "Provisional restoration fabrication, occlusion check and cementation",
      "trigger": "The impression or scan is done and the tooth must be protected until delivery",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, try-in/delivery dependency)",
          "source": "Class taxonomy floor: DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis, try-in/delivery dependency)"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for ceramics (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for ceramics (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "rind-008",
      "kind": "clinical",
      "materials": [
        "dental floss",
        "articulating paper",
        "try-in paste or water for shade verification (bonded ceramics)",
        "fine diamond/polishing points for minor adjustment",
        "hand mirror for patient esthetic review"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the signed consent for the crown/veneer/bridge procedure is already in the chart before removing the provisional and seating the final restoration.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent for the overall procedure is on file.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent for the overall procedure is on file"
        },
        {
          "detail": "Remove the provisional restoration and cement remnants, and clean the prepared tooth/teeth before seating the final restoration.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Remove the provisional and clean the preparation"
        },
        {
          "detail": "Seat the final restoration and confirm it fully seats without rocking, gaps, or resistance beyond normal contact tightness.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the restoration and check fit"
        },
        {
          "detail": "Are margins closed and continuous?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "yes",
              "label": "Margins closed, no open margin or overhang"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "Open margin, overhang, or the restoration does not fully seat"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Are margins closed and continuous?"
        },
        {
          "detail": "Check that floss passes through each proximal contact with resistance but does not shred or pass with no resistance at all.\n\nWhy: An open contact traps food; a too-tight contact prevents full seating or causes patient discomfort flossing.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Check proximal contacts with floss",
          "why": "An open contact traps food; a too-tight contact prevents full seating or causes patient discomfort flossing."
        },
        {
          "detail": "Have the patient bite on articulating paper in maximum intercuspation and check lateral/protrusive excursions; adjust only minor high spots per the practice's adjustment authority.\n\nRecord: Occlusion checked, adjustments noted in the SOAP note",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Check occlusion in maximum intercuspation and excursions"
        },
        {
          "detail": "Is this an esthetic case requiring patient approval before final cementation?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "Yes — anterior crown, veneer or bridge case"
            },
            {
              "goto": "s9",
              "id": "no",
              "label": "No — posterior, non-esthetic case"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this an esthetic case requiring patient approval before final cementation?"
        },
        {
          "detail": "Give the patient a hand mirror to review shade, shape and contour before final cementation, and record their approval or requested changes.\n\nWhy: A bonded ceramic esthetic case is difficult to undo once cemented, so approval belongs before that step, not after.\n\nRecord: Patient esthetic approval or requested change logged",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Have the patient review shade and shape with a mirror",
          "why": "A bonded ceramic esthetic case is difficult to undo once cemented, so approval belongs before that step, not after."
        },
        {
          "detail": "Fit, contacts, occlusion and (where applicable) esthetics are verified; proceed to adhesive cementation (rind-009) or conventional cementation (rind-010) per the material.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to cementation"
        },
        {
          "detail": "Log fit, contact, occlusion and esthetic review findings, and next-step cementation path chosen, in the SOAP note.\n\nRecord: Procedure note with try-in verification results",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the try-in"
        },
        {
          "detail": "Try-in complete, ready for cementation or remake",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Try-in complete, ready for cementation or remake"
        },
        {
          "detail": "Do not cement; stop and follow the crown remake decision protocol (rind-012) for the fit failure found.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Divert to the remake protocol"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Try-in — fit, contacts, margins, occlusion and esthetics verification — The lab case has returned and the patient is seated for delivery.",
      "title": "Try-in — fit, contacts, margins, occlusion and esthetics verification",
      "trigger": "The lab case has returned and the patient is seated for delivery",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 — provisional cementation with temporary cement ONLY; it is a class-taxonomy anchor and does not support final adhesive bonding, conventional cementation technique, or debonded-crown reassessment",
          "ruled": {
            "action": "narrow_claim",
            "ruling": "F-2026-09-05-R2",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis)"
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 — provisional cementation with temporary cement ONLY; it is a class-taxonomy anchor and does not support final adhesive bonding, conventional cementation technique, or debonded-crown reassessment"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 (hydrofluoric acid etchant SDS — hazardous material handling)",
          "source": "OSHA 29 CFR 1910.1200 (hydrofluoric acid etchant SDS — hazardous material handling)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "rind-009",
      "kind": "clinical",
      "materials": [
        "try-in paste kit matched to final cement shade",
        "rubber dam or isolation system",
        "etchant (hydrofluoric acid gel for glass-ceramic, or per material) and phosphoric acid etchant for enamel/dentin",
        "silane coupling agent",
        "dual-cure or light-cure resin cement",
        "bonding/adhesive agent",
        "curing light with calibrated output",
        "articulating paper",
        "floss",
        "protective eyewear for patient and staff"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist confirms the chart shows try-in was approved for fit, contacts, margins, occlusion and esthetics before opening the cementation kit.\n\nWhy: Cementation is difficult to reverse; proceeding without a documented approval risks bonding a restoration that still needs adjustment.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm try-in approval is documented before proceeding",
          "why": "Cementation is difficult to reverse; proceeding without a documented approval risks bonding a restoration that still needs adjustment."
        },
        {
          "detail": "Assistant places rubber dam where feasible, or an equivalent isolation method (retraction cord plus cotton roll/dry-field system) if a dam cannot be used.\n\nWhy: Contamination of the etched or silanated bonding surface by saliva or blood is the leading cause of early debonding.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate the operative field",
          "why": "Contamination of the etched or silanated bonding surface by saliva or blood is the leading cause of early debonding."
        },
        {
          "detail": "Dentist places try-in paste matched to the planned cement shade under the restoration, evaluates esthetics with the patient in natural or color-corrected light, and confirms acceptance before committing.\n\nWhy: Resin cement shade shifts the final appearance of translucent ceramics; this is the last reversible checkpoint before permanent bonding.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Select cement shade using try-in paste and verify with the patient",
          "why": "Resin cement shade shifts the final appearance of translucent ceramics; this is the last reversible checkpoint before permanent bonding."
        },
        {
          "detail": "Dentist confirms whether the restoration is a glass-ceramic (etchable with hydrofluoric acid) or a zirconia/high-strength ceramic (not HF-etchable, requires a different surface treatment).\n\nWhy: Applying the wrong etch protocol either fails to roughen the bonding surface or damages a material that should not be HF-etched.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "glass-ceramic",
              "label": "Glass-ceramic — HF etch + silane"
            },
            {
              "goto": "s13",
              "id": "zirconia-like",
              "label": "Zirconia or non-etchable ceramic — route to conventional cementation"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm restoration material family before etch protocol",
          "why": "Applying the wrong etch protocol either fails to roughen the bonding surface or damages a material that should not be HF-etched."
        },
        {
          "detail": "Assistant or dentist applies hydrofluoric acid gel to the restoration extraorally only (held in a bur block or dappen dish, never intraorally or near patient skin/soft tissue) per the material's instructions for use, rinses and dries thoroughly, then applies silane coupling agent and allows it to react per manufacturer time before air-drying. Keep calcium gluconate gel accessible per the product SDS in case of accidental skin contact.\n\nWhy: Hydrofluoric acid is systemically toxic and tissue-necrotizing even in small volumes; silane chemically bonds the resin cement to the etched glass-ceramic surface, and skipping or rushing either step is a documented cause of debonding.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "hydrofluoric acid gel",
            "silane coupling agent"
          ],
          "role": "assistant",
          "title": "Etch and silanate the intaglio surface of the restoration",
          "why": "Hydrofluoric acid is systemically toxic and tissue-necrotizing even in small volumes; silane chemically bonds the resin cement to the etched glass-ceramic surface, and skipping or rushing either step is a documented cause of debonding."
        },
        {
          "detail": "Dentist applies phosphoric acid etchant to enamel (and dentin per the bonding system's protocol), rinses, controls moisture, and applies the bonding/adhesive agent, light-curing per manufacturer instructions.\n\nWhy: A properly conditioned tooth surface is the other half of the adhesive bond; under- or over-etching either surface compromises retention.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "phosphoric acid etchant",
            "bonding agent"
          ],
          "role": "dentist",
          "title": "Etch and bond the prepared tooth surface",
          "why": "A properly conditioned tooth surface is the other half of the adhesive bond; under- or over-etching either surface compromises retention."
        },
        {
          "detail": "Dentist confirms shade, contacts, margins and occlusion were all previously approved at try-in and gives the go-ahead to seat and cure, since adhesive cementation cannot be undone without damaging the restoration.\n\nWhy: Once cured, an adhesively bonded ceramic restoration cannot be removed without sectioning it; this is the final checkpoint before an irreversible step.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms readiness to permanently bond the restoration.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms readiness to permanently bond the restoration",
          "why": "Once cured, an adhesively bonded ceramic restoration cannot be removed without sectioning it; this is the final checkpoint before an irreversible step."
        },
        {
          "detail": "Dentist loads resin cement into the restoration, seats it under firm finger pressure, removes gross excess with a brush or explorer, tack-cures at line angles, then fully cures each surface per the curing light's rated exposure time.\n\nWhy: Removing gross excess before full cure prevents a flash of set cement locking under the margin; tack-curing holds the restoration in place while excess is cleaned.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "resin cement",
            "curing light"
          ],
          "role": "dentist",
          "title": "Seat the restoration with cement and cure",
          "why": "Removing gross excess before full cure prevents a flash of set cement locking under the margin; tack-curing holds the restoration in place while excess is cleaned."
        },
        {
          "detail": "Dentist scales away remaining flash cement at the margins with hand instruments and passes floss through each proximal contact to confirm no cement ligature remains.\n\nWhy: Residual subgingival cement is a leading cause of localized inflammation around an otherwise well-fitted restoration.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Remove residual cement and pass floss through every contact",
          "why": "Residual subgingival cement is a leading cause of localized inflammation around an otherwise well-fitted restoration."
        },
        {
          "detail": "Confirm: articulating paper marks even contact in maximum intercuspation; no premature contact on the new restoration; excursive movements are free of interference; floss contacts are tight but pass; margins are smooth to explorer.\n\nWhy: A high spot left uncorrected after cementation is difficult to adjust without risking the ceramic and is the most common source of a callback.",
          "id": "s10",
          "kind": "step",
          "materials": [
            "articulating paper",
            "floss"
          ],
          "role": "dentist",
          "title": "Verify occlusion, contacts and margins after cementation",
          "why": "A high spot left uncorrected after cementation is difficult to adjust without risking the ceramic and is the most common source of a callback."
        },
        {
          "detail": "Chart the restoration material, cement brand/lot, isolation method used, and occlusal adjustments made; give the patient written post-op instructions covering expected sensitivity and when to call.\n\nWhy: Cement lot documentation supports traceability if a batch-related bonding issue surfaces later across multiple patients.\n\nRecord: restoration material, cement shade/lot, isolation method, occlusal adjustments, post-op instructions given",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document the cementation and give post-op instructions",
          "why": "Cement lot documentation supports traceability if a batch-related bonding issue surfaces later across multiple patients."
        },
        {
          "detail": "Cementation visit complete",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Cementation visit complete"
        },
        {
          "detail": "Dentist stops this adhesive workflow and follows the conventional cementation protocol (rind-010) instead, since the material does not accept HF etch/silane bonding.\n\nWhy: Using the wrong protocol for a non-etchable ceramic wastes the etchant and risks damaging the restoration surface.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the conventional cementation protocol",
          "why": "Using the wrong protocol for a non-etchable ceramic wastes the etchant and risks damaging the restoration surface."
        },
        {
          "detail": "Diverted to conventional cementation (rind-010) — this workflow stops here",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Diverted to conventional cementation (rind-010) — this workflow stops here"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Adhesive cementation or bonding of a ceramic restoration — Try-in is approved for a bonded ceramic (veneer, onlay, glass-ceramic crown).",
      "title": "Adhesive cementation or bonding of a ceramic restoration",
      "trigger": "Try-in is approved for a bonded ceramic (veneer, onlay, glass-ceramic crown)",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 — provisional cementation with temporary cement ONLY; it is a class-taxonomy anchor and does not support final adhesive bonding, conventional cementation technique, or debonded-crown reassessment",
          "ruled": {
            "action": "narrow_claim",
            "ruling": "F-2026-09-05-R2",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis)"
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 — provisional cementation with temporary cement ONLY; it is a class-taxonomy anchor and does not support final adhesive bonding, conventional cementation technique, or debonded-crown reassessment"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for cements (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for cements (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "rind-010",
      "kind": "clinical",
      "materials": [
        "conventional or resin-modified glass ionomer cement",
        "cotton rolls or dry-field isolation",
        "articulating paper",
        "floss",
        "explorer",
        "cement gun or mixing pad and spatula"
      ],
      "needs_ack_review": true,
      "outcomes": [
        "sensitivity_48h",
        "remake_12m",
        "patient_reported_scale"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist confirms the chart shows try-in was approved for fit, margins, contacts and occlusion before opening the cementation kit.\n\nWhy: This is the last reversible checkpoint before a cement that is difficult to remove without sectioning the crown.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm try-in approval is documented before proceeding",
          "why": "This is the last reversible checkpoint before a cement that is difficult to remove without sectioning the crown."
        },
        {
          "detail": "Assistant places cotton rolls or a dry-field isolation device and dries the preparation; saliva control is maintained through cementation.\n\nWhy: Glass ionomer cements are moisture-sensitive during initial set; contamination weakens the bond.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Isolate and dry the preparation",
          "why": "Glass ionomer cements are moisture-sensitive during initial set; contamination weakens the bond."
        },
        {
          "detail": "Assistant mixes conventional or resin-modified glass ionomer cement per the powder/liquid ratio or capsule instructions and working time on the label.\n\nWhy: Over- or under-mixing changes set time and film thickness, which can prevent full seating of the crown.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "glass ionomer cement"
          ],
          "role": "assistant",
          "title": "Mix cement to manufacturer specification",
          "why": "Over- or under-mixing changes set time and film thickness, which can prevent full seating of the crown."
        },
        {
          "detail": "Dentist confirms fit, margins, contacts and occlusion were all previously approved at try-in and gives the go-ahead to seat, since a fully seated conventional cement crown is difficult to remove without sectioning it.\n\nWhy: This is the final checkpoint before a hard-to-reverse step; the dentist, not the assistant mixing cement, owns this decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms readiness to permanently cement the crown.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms readiness to permanently cement the crown",
          "why": "This is the final checkpoint before a hard-to-reverse step; the dentist, not the assistant mixing cement, owns this decision."
        },
        {
          "detail": "Dentist loads cement into the crown, seats it fully on the preparation under firm finger or bite-stick pressure, and holds until the cement reaches initial set per the manufacturer's timing.\n\nWhy: Incomplete seating is the most common cause of a high occlusal contact discovered later.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Load and seat the crown under firm pressure",
          "why": "Incomplete seating is the most common cause of a high occlusal contact discovered later."
        },
        {
          "detail": "Dentist removes bulk excess cement once it reaches a rubbery consistency using hand instruments, then passes floss through each proximal contact from the facial or lingual to avoid pulling excess subgingivally.\n\nWhy: Removing cement too early smears it; too late makes it difficult to remove without gouging the margin.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Remove excess cement at the gel/rubbery stage",
          "why": "Removing cement too early smears it; too late makes it difficult to remove without gouging the margin."
        },
        {
          "detail": "Confirm: articulating paper marks even contact in maximum intercuspation; no premature contact; excursive movements clear; floss contacts pass; margins smooth to explorer; no residual cement at the sulcus.\n\nWhy: A retained subgingival cement fragment on a non-etched crown is a common, avoidable cause of localized gum inflammation.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "articulating paper",
            "floss",
            "explorer"
          ],
          "role": "dentist",
          "title": "Verify occlusion, contacts and margins after cementation",
          "why": "A retained subgingival cement fragment on a non-etched crown is a common, avoidable cause of localized gum inflammation."
        },
        {
          "detail": "Chart the restoration material, cement type/lot, and occlusal adjustments made; give the patient written post-op instructions covering expected mild sensitivity and when to call.\n\nWhy: Documenting cement type distinguishes conventional-cement sensitivity patterns from bonded-restoration patterns if a follow-up call comes in.\n\nRecord: restoration material, cement type/lot, occlusal adjustments, post-op instructions given",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the cementation and give post-op instructions",
          "why": "Documenting cement type distinguishes conventional-cement sensitivity patterns from bonded-restoration patterns if a follow-up call comes in."
        },
        {
          "detail": "Cementation visit complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Cementation visit complete"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Conventional cementation of a metal or zirconia crown — Try-in is approved for a retentive preparation on a non-etchable material.",
      "title": "Conventional cementation of a metal or zirconia crown",
      "trigger": "Try-in is approved for a retentive preparation on a non-etchable material",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 — provisional cementation with temporary cement ONLY; it is a class-taxonomy anchor and does not support final adhesive bonding, conventional cementation technique, or debonded-crown reassessment",
          "ruled": {
            "action": "narrow_claim",
            "ruling": "F-2026-09-05-R2",
            "was": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 (in-repo crown preparation basis)"
          },
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §4.3 — provisional cementation with temporary cement ONLY; it is a class-taxonomy anchor and does not support final adhesive bonding, conventional cementation technique, or debonded-crown reassessment"
        },
        {
          "kind": "regulation",
          "label": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "source": "FDA device labeling / instructions for use for cements and ceramics (21 CFR Part 872)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-872"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rind-014",
      "kind": "clinical",
      "materials": [
        "resin cement or conventional cement matched to restoration material",
        "etchant and silane for ceramic recementation",
        "explorer and hand scaler for residual cement removal",
        "articulating paper",
        "storage container for the restoration if the patient brings it in loose"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Front desk asks the patient to bring in the restoration if they still have it and not to try to recement it themselves, and books a visit as soon as reasonably possible.\n\nWhy: A prepared tooth left uncovered is vulnerable to fracture, drift and sensitivity, and improvised home recementation risks improper seating.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Front desk confirms the patient has the restoration",
          "why": "A prepared tooth left uncovered is vulnerable to fracture, drift and sensitivity, and improvised home recementation risks improper seating."
        },
        {
          "detail": "Dentist examines the restoration for cracks or wear, and examines the abutment tooth for new decay, fracture, or a change in the preparation since cementation.\n\nWhy: Debonding is sometimes a symptom of an underlying problem (new caries under the margin, a cracked tooth) rather than a simple cement failure.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the patient and inspect both the restoration and the tooth",
          "why": "Debonding is sometimes a symptom of an underlying problem (new caries under the margin, a cracked tooth) rather than a simple cement failure."
        },
        {
          "detail": "Dentist determines whether the cause appears to be new decay under the margin, a fractured tooth or restoration, occlusal overload, or simple cement failure with a sound restoration and tooth.\n\nWhy: Recementing over active decay or a cracked tooth without addressing it guarantees a repeat failure and can allow the underlying problem to worsen.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "sound",
              "label": "Restoration and tooth both sound, cement failure only"
            },
            {
              "goto": "s11",
              "id": "underlying-problem",
              "label": "New decay, fracture, or other underlying problem found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Identify the likely cause of debonding",
          "why": "Recementing over active decay or a cracked tooth without addressing it guarantees a repeat failure and can allow the underlying problem to worsen."
        },
        {
          "detail": "Dentist removes all residual old cement from the intaglio surface of the restoration and from the preparation with hand instruments, taking care not to alter the preparation geometry.\n\nWhy: Old cement left in place increases film thickness and prevents full reseating.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Clean residual cement from both surfaces",
          "why": "Old cement left in place increases film thickness and prevents full reseating."
        },
        {
          "detail": "Dentist confirms whether the restoration is an etchable ceramic (veneer, glass-ceramic) or a non-etchable material (zirconia, metal), to choose the correct recementation approach.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "etchable",
              "label": "Etchable ceramic — adhesive recementation"
            },
            {
              "goto": "s13",
              "id": "nonetchable",
              "label": "Non-etchable — conventional recementation"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Confirm restoration material to select the recementation protocol"
        },
        {
          "detail": "Dentist confirms the tooth and restoration are sound (or the underlying problem was already addressed) and gives the go-ahead to permanently rebond.\n\nWhy: Recementation is the last chance to catch a missed underlying cause before it is sealed under the restoration again.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms readiness to permanently recement.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms readiness to permanently recement",
          "why": "Recementation is the last chance to catch a missed underlying cause before it is sealed under the restoration again."
        },
        {
          "detail": "Dentist etches and silanates the restoration's intaglio surface, etches and bonds the tooth, and seats the restoration with resin cement, curing per manufacturer instructions.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "etchant and silane for ceramic recementation",
            "resin cement or conventional cement matched to restoration material"
          ],
          "role": "dentist",
          "title": "Etch, silanate and adhesively recement"
        },
        {
          "detail": "Dentist checks occlusal contact with articulating paper, adjusts if needed, and confirms margins are smooth and fully seated.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "articulating paper"
          ],
          "role": "dentist",
          "title": "Verify occlusion and margins after recementation"
        },
        {
          "detail": "Chart the identified cause of debonding, any treatment performed for an underlying problem, the cement used, and occlusal findings.\n\nRecord: cause of debonding, underlying treatment if any, cement used, occlusal adjustment made",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the debond assessment and recementation"
        },
        {
          "detail": "Recementation visit complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Recementation visit complete"
        },
        {
          "detail": "Dentist treats the underlying issue found (for example, removes new decay and places a build-up, or determines the tooth or restoration needs to be remade) before any recementation proceeds.\n\nWhy: Sealing a known problem under a recemented crown converts a fixable finding into a hidden one.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Address the underlying problem before recementing",
          "why": "Sealing a known problem under a recemented crown converts a fixable finding into a hidden one."
        },
        {
          "detail": "Dentist decides whether, after addressing the underlying problem, the original restoration still fits and can be recemented, or whether the changes require a remake.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "still-fits",
              "label": "Restoration still fits after treatment"
            },
            {
              "goto": "s15",
              "id": "needs-remake",
              "label": "Restoration no longer fits"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether the existing restoration can still be reused"
        },
        {
          "detail": "Dentist confirms the tooth and restoration are sound (or the underlying problem was already addressed) and gives the go-ahead to permanently recement.\n\nWhy: Recementation is the last chance to catch a missed underlying cause before it is sealed under the restoration again.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms readiness to permanently recement.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms readiness to permanently recement",
          "why": "Recementation is the last chance to catch a missed underlying cause before it is sealed under the restoration again."
        },
        {
          "detail": "Dentist mixes conventional or resin-modified glass ionomer cement, loads the restoration, and seats it under firm pressure until set.",
          "id": "s14",
          "kind": "step",
          "materials": [
            "resin cement or conventional cement matched to restoration material"
          ],
          "role": "dentist",
          "title": "Recement conventionally"
        },
        {
          "detail": "Dentist stops this recementation workflow and follows the crown remake protocol (rind-012) to send the case back to the lab.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the remake protocol"
        },
        {
          "detail": "Handed off to remake process",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Handed off to remake process"
        }
      ],
      "subclass": "fixed-prosthodontics-crowns-veneers-and-bridges",
      "summary": "Debonded crown or veneer assessment and recementation — A previously cemented restoration comes off.",
      "title": "Debonded crown or veneer assessment and recementation",
      "trigger": "A previously cemented restoration comes off",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        },
        {
          "kind": "public_domain",
          "label": "CDC guidance on disinfecting impressions and prostheses",
          "source": "CDC guidance on disinfecting impressions and prostheses",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-patient",
      "id": "rpd-001",
      "kind": "clinical",
      "materials": [
        "stock edentulous impression trays",
        "irreversible hydrocolloid or equivalent preliminary material",
        "custom tray material (light-cured or self-cured resin)",
        "border molding compound (green stick or equivalent)",
        "final impression material (polyvinyl siloxane or polyether)",
        "laboratory work order form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Review the treatment plan, ridge condition, and medical history; confirm the patient has accepted complete dentures and understands the multi-visit process.\n\nWhy: Records taken before candidacy and consent are settled are often redone once expectations are clarified.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the patient is a complete-denture candidate",
          "why": "Records taken before candidacy and consent are settled are often redone once expectations are clarified."
        },
        {
          "detail": "Confirm a signed consent for complete denture treatment is in the chart, or complete the consent conversation now, before taking any impression.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Informed consent on file before impressions.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Informed consent on file before impressions"
        },
        {
          "detail": "Select stock edentulous trays sized to the patient's arches, try in for coverage of the full denture-bearing area without impinging on movable tissue, and adjust the tray borders as needed.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Select and fit stock trays"
        },
        {
          "detail": "Take a preliminary impression of each arch with the fitted stock tray, capturing the full denture-bearing area and reflection of the vestibule.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Take preliminary impressions of both arches"
        },
        {
          "detail": "Rinse and disinfect each impression per the public infection-control guidance before pouring the cast or sending it to the laboratory.\n\nWhy: Impressions carry saliva and are treated as a contaminated item until disinfected.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect impressions before pouring or shipping",
          "why": "Impressions carry saliva and are treated as a contaminated item until disinfected."
        },
        {
          "detail": "Pour the preliminary casts and either fabricate custom trays chairside or send the casts to the laboratory with a written work order requesting custom trays.\n\nRecord: Laboratory work order with case details, no patient identifiers beyond what the order requires",
          "id": "s6",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Order or fabricate custom trays"
        },
        {
          "detail": "If the custom tray is fabricated chairside, proceed to try-in the same visit; if the casts were sent to an outside laboratory, schedule a return visit once the custom tray is received and confirm arrival before the appointment.\n\nWhy: Custom tray fabrication commonly involves outside laboratory turnaround; this protocol spans more than one appointment when that is the case.",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Schedule the custom tray try-in visit",
          "why": "Custom tray fabrication commonly involves outside laboratory turnaround; this protocol spans more than one appointment when that is the case."
        },
        {
          "detail": "Seat the custom tray, check border extension against the moving tissues, and adjust short or overextended borders with a bur before border molding.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Try in the custom tray"
        },
        {
          "detail": "Add border molding compound in sections around the tray periphery, guiding the patient through functional movements (cheek pull, tongue movement, swallowing) to shape each border to the moving tissue.\n\nWhy: Accurate border molding is what gives a complete denture peripheral seal and retention; a short or overextended border causes looseness or sore spots.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Border mold the custom tray",
          "why": "Accurate border molding is what gives a complete denture peripheral seal and retention; a short or overextended border causes looseness or sore spots."
        },
        {
          "detail": "Load the border-molded custom tray with final impression material and seat it with light, even pressure, holding until set, then evaluate for full extension and absence of voids.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Take the final impression"
        },
        {
          "detail": "Rinse and disinfect the final impression, inspect for voids or drags, and repeat the impression if the critical border areas are not fully captured.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect and inspect the final impression"
        },
        {
          "detail": "Complete a written laboratory work order specifying master cast pour and custom record base with occlusal rim fabrication, and ship the disinfected final impressions.\n\nRecord: Laboratory work order logged with case number and date sent",
          "id": "s12",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send master impressions to the laboratory"
        },
        {
          "detail": "Log the impression materials used, tray adjustments made, and laboratory shipment details in the chart.\n\nRecord: Procedure note with materials and lab shipment reference",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Document the visit"
        },
        {
          "detail": "Final impressions complete, case sent to laboratory",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Final impressions complete, case sent to laboratory"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Complete denture — preliminary impressions, custom tray, border molding, final impression — An edentulous patient is accepted for complete dentures.",
      "title": "Complete denture — preliminary impressions, custom tray, border molding, final impression",
      "trigger": "An edentulous patient is accepted for complete dentures",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "rpd-002",
      "kind": "clinical",
      "materials": [
        "record bases with occlusal rims",
        "facebow (optional, per office protocol)",
        "bite registration material",
        "shade guide and mold guide for denture teeth",
        "millimeter ruler or Willis gauge equivalent"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Seat each record base and check for stability and retention on the ridge, then evaluate the occlusal rim height and contour against the lip support and smile line.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Evaluate record base fit and rim contour"
        },
        {
          "detail": "Measure vertical dimension at rest, subtract an interocclusal freeway space appropriate to the patient, and adjust the rims to that vertical dimension of occlusion.\n\nWhy: Setting the bite too open or too closed changes speech, appearance, and jaw comfort for the life of the denture, so this is verified before any tooth is set.\n\nRecord: Rest and occlusal vertical dimension measurements in the chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Establish vertical dimension of occlusion",
          "why": "Setting the bite too open or too closed changes speech, appearance, and jaw comfort for the life of the denture, so this is verified before any tooth is set."
        },
        {
          "detail": "Guide the patient into centric relation and record the jaw relationship with a bite registration material between the rims.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Record centric relation"
        },
        {
          "detail": "Decide whether to take a facebow transfer",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "facebow",
              "label": "Take a facebow transfer for the laboratory articulator"
            },
            {
              "goto": "s5",
              "id": "no-facebow",
              "label": "Use average articulator values without a facebow"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether to take a facebow transfer"
        },
        {
          "detail": "Select a denture tooth shade against the patient's skin tone and preference under natural or shade-corrected lighting.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Select denture tooth shade"
        },
        {
          "detail": "Select a tooth mold and size consistent with the patient's facial form, arch width, and midline/smile-line measurements taken from the rims.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Select denture tooth mold and size"
        },
        {
          "detail": "Mark the facial midline, high smile line, and canine line on the wax rims so the laboratory sets teeth to the patient's own anatomy.\n\nRecord: Reference marks documented as part of the case record",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Mark reference lines on the rims"
        },
        {
          "detail": "The treating dentist reviews and confirms the vertical dimension, centric relation record, reference marks, and the selected tooth shade and mold are correct before they are sent to the laboratory and become the basis for tooth setting.\n\nWhy: An error in vertical dimension or centric relation carries through the entire remaining fabrication sequence, so a licensed clinician confirms the records before they leave the office.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on jaw relation records before shipment.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on jaw relation records before shipment",
          "why": "An error in vertical dimension or centric relation carries through the entire remaining fabrication sequence, so a licensed clinician confirms the records before they leave the office."
        },
        {
          "detail": "Complete a written laboratory work order specifying vertical dimension, centric relation record, facebow transfer if taken, and selected tooth shade and mold, then ship the records.\n\nRecord: Laboratory work order logged with case number and date sent",
          "id": "s9",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send jaw relation records to the laboratory"
        },
        {
          "detail": "Log vertical dimension, centric relation method, shade, and mold selection in the chart.\n\nRecord: Procedure note with jaw relation and tooth selection details",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the visit"
        },
        {
          "detail": "Jaw relation records complete, case sent to laboratory",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Jaw relation records complete, case sent to laboratory"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Jaw relation records, vertical dimension and tooth selection — Master casts return with record bases.",
      "title": "Jaw relation records, vertical dimension and tooth selection",
      "trigger": "Master casts return with record bases",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "rpd-003",
      "kind": "clinical",
      "materials": [
        "wax denture try-in (upper and lower)",
        "hand mirror for patient",
        "articulating paper",
        "written approval form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "patient",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Seat the wax try-in bases and confirm they fit the casts and the patient's mouth without binding.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the wax try-in"
        },
        {
          "detail": "Have the patient close and confirm the vertical dimension and centric relation set in the previous visit were reproduced correctly by the laboratory.\n\nWhy: This is the last point where a vertical-dimension or bite error can be corrected before the denture is processed in acrylic.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Verify vertical dimension and occlusal contact in wax",
          "why": "This is the last point where a vertical-dimension or bite error can be corrected before the denture is processed in acrylic."
        },
        {
          "detail": "Hand the patient a mirror and evaluate tooth shade, shape, midline position, lip support, and how much tooth shows at rest and in a full smile.\n\nRecord: Esthetic evaluation notes",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Evaluate esthetics with the patient"
        },
        {
          "detail": "Have the patient read a short list of words containing sibilant and labiodental sounds and listen for whistling, lisping, or difficulty forming sounds.\n\nWhy: A vertical dimension that is too closed or too open, or teeth set too far lingual or facial, most often shows up first as a speech problem before the patient notices anything else.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Check phonetics",
          "why": "A vertical dimension that is too closed or too open, or teeth set too far lingual or facial, most often shows up first as a speech problem before the patient notices anything else."
        },
        {
          "detail": "Patient satisfied with esthetics and speech?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "approved",
              "label": "Patient approves the try-in as presented"
            },
            {
              "goto": "s10",
              "id": "revise",
              "label": "Patient requests changes to shade, tooth position, or arrangement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Patient satisfied with esthetics and speech?"
        },
        {
          "detail": "Have the patient sign or initial a written approval form confirming they accept the try-in's appearance, fit, and speech before the case is authorized for processing.\n\nWhy: Complete dentures are processed in acrylic after this step and cannot be reset without remaking; written sign-off protects both the patient's expectations and the practice's record.\n\nRecord: Signed or initialed try-in approval form in the chart",
          "gate": {
            "ack": "I confirm I have completed this step as written: Obtain written patient approval before processing.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "patient",
          "title": "Obtain written patient approval before processing",
          "why": "Complete dentures are processed in acrylic after this step and cannot be reset without remaking; written sign-off protects both the patient's expectations and the practice's record."
        },
        {
          "detail": "Send written authorization to the laboratory to process the approved try-in into the final acrylic denture.\n\nRecord: Laboratory work order authorizing final processing",
          "id": "s7",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Authorize processing to final denture"
        },
        {
          "detail": "Log the esthetic and phonetic evaluation, patient approval, and processing authorization in the chart.\n\nRecord: Procedure note with try-in approval reference",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the visit"
        },
        {
          "detail": "Try-in approved, case sent for final processing",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Try-in approved, case sent for final processing"
        },
        {
          "detail": "Write specific revision instructions (which teeth, which direction, shade change) and send the try-in back to the laboratory for re-setting.\n\nRecord: Laboratory work order with itemized revision requests",
          "id": "s10",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send revision instructions to the laboratory"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Wax try-in — esthetics, phonetics, occlusion and written patient approval — Teeth set in wax return from the lab.",
      "title": "Wax try-in — esthetics, phonetics, occlusion and written patient approval",
      "trigger": "Teeth set in wax return from the lab",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "public_domain",
          "label": "CDC guidance on disinfecting impressions and prostheses",
          "source": "CDC guidance on disinfecting impressions and prostheses",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "rpd-004",
      "kind": "clinical",
      "materials": [
        "processed complete or partial dentures",
        "articulating paper",
        "pressure-indicating paste or spray",
        "acrylic adjustment burs",
        "denture home-care instruction sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Rinse and disinfect the denture per the public infection-control guidance before it touches the patient's mouth.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the returned prosthesis before delivery"
        },
        {
          "detail": "Seat the denture and check for full seating, tissue blanching, and any binding areas using pressure-indicating paste or spray on sore-spot-prone areas.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Seat and evaluate fit"
        },
        {
          "detail": "The treating dentist confirms the fit findings and the planned adjustment areas before any acrylic is removed from the denture base.\n\nWhy: Acrylic removal cannot be undone; a licensed clinician confirms the adjustment plan before an assistant or the dentist begins grinding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms fit before irreversible adjustment.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms fit before irreversible adjustment",
          "why": "Acrylic removal cannot be undone; a licensed clinician confirms the adjustment plan before an assistant or the dentist begins grinding."
        },
        {
          "detail": "Relieve any area showing pressure-indicating material breakthrough or patient-reported pinching, working conservatively.\n\nWhy: Over-adjusting an area weakens retention; small, iterative relief is safer than a single large reduction.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Adjust borders and relief areas",
          "why": "Over-adjusting an area weakens retention; small, iterative relief is safer than a single large reduction."
        },
        {
          "detail": "Have the patient bite on articulating paper in centric and lateral excursions and equilibrate any premature contacts.\n\nRecord: Occlusal adjustment at delivery noted in the chart",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Check and adjust occlusion at delivery"
        },
        {
          "detail": "Demonstrate how to insert and remove the denture, and give the patient written home-care instructions covering nightly removal, cleaning method, and soaking.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Teach insertion, removal and home care"
        },
        {
          "detail": "Explain that some looseness, excess salivation, and speech adjustment are expected in the first days, and sore spots are normal and addressed at the follow-up visit rather than by the patient adjusting the denture themselves.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Set expectations for the adjustment period"
        },
        {
          "detail": "Schedule a follow-up visit within 24 to 72 hours for a sore-spot and fit check, and advise the patient to wear the denture continuously up to that visit so sore areas are identifiable.\n\nWhy: Sore spots are easiest to locate and adjust while the pressure mark from wearing is still visible on the tissue.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Schedule the 24–72 hour adjustment visit",
          "why": "Sore spots are easiest to locate and adjust while the pressure mark from wearing is still visible on the tissue."
        },
        {
          "detail": "At the follow-up visit, identify sore or pressure areas by direct inspection and pressure-indicating material, and relieve the denture base at those points.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Conduct the follow-up adjustment visit"
        },
        {
          "detail": "Additional adjustment visits needed?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "resolved",
              "label": "Patient comfortable, no further adjustment needed"
            },
            {
              "goto": "s9",
              "id": "more-visits",
              "label": "Sore spots remain, schedule another adjustment visit"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Additional adjustment visits needed?"
        },
        {
          "detail": "Log all adjustments made across delivery and follow-up visits, and the date the patient was declared comfortable.\n\nRecord: Procedure notes for delivery and each adjustment visit",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document delivery and adjustments"
        },
        {
          "detail": "Denture delivered and adjustment sequence complete",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Denture delivered and adjustment sequence complete"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Denture delivery, occlusal check and 24–72 hour adjustment visit — The processed denture is returned and the patient is seated.",
      "title": "Denture delivery, occlusal check and 24–72 hour adjustment visit",
      "trigger": "The processed denture is returned and the patient is seated",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "source": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2023-title29-vol6/pdf/CFR-2023-title29-vol6-sec1910-1200.pdf",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "Pre-extraction medical history review, vital signs, and local anesthesia administration — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Pre-extraction medical history review, vital signs, and local anesthesia administration — generic functional description"
          },
          "source": "Pre-extraction medical history review, vital signs, and local anesthesia administration — generic functional description — Practice policy — no published authority governs this step."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "per-patient",
      "id": "rpd-005",
      "kind": "clinical",
      "materials": [
        "pre-fabricated immediate denture(s)",
        "local anesthetic and delivery supplies",
        "extraction instruments",
        "sutures",
        "hemostatic materials (gauze, hemostatic agent)",
        "tissue conditioner or soft reline material",
        "post-extraction and denture home-care instruction sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm a signed consent covering the extraction sequence, immediate denture insertion, and the likelihood of a reline or remake once the ridges heal, before starting.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm consent for extractions and immediate denture.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm consent for extractions and immediate denture"
        },
        {
          "detail": "Confirm the immediate denture fits the pre-extraction cast and the planned extraction sites correspond to the teeth set up for removal.\n\nWhy: The denture was processed on a cast made before extraction; a mismatch caught now is far cheaper than one discovered after teeth are already out.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Verify the pre-fabricated denture on the pre-extraction cast",
          "why": "The denture was processed on a cast made before extraction; a mismatch caught now is far cheaper than one discovered after teeth are already out."
        },
        {
          "detail": "Review the patient's medical history, medication list, and allergies (including local anesthetic and latex allergies) and take vitals appropriate to the planned extractions, then administer and document local anesthesia to the extraction sites before any tooth is elevated.\n\nWhy: Extractions are irreversible and painful; confirming no anesthetic contraindication and achieving profound anesthesia is done before instrumentation begins, not discovered partway through.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Review medical history and administer local anesthesia",
          "why": "Extractions are irreversible and painful; confirming no anesthetic contraindication and achieving profound anesthesia is done before instrumentation begins, not discovered partway through."
        },
        {
          "detail": "Extract the remaining teeth in the planned sequence, using minimally traumatic technique to preserve ridge form for the immediate denture.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Extract the remaining teeth"
        },
        {
          "detail": "Bony recontouring needed before seating?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "smooth",
              "label": "Recontour undercuts or sharp bony edges before seating the denture"
            },
            {
              "goto": "s6",
              "id": "none",
              "label": "Ridge form is favorable, no recontouring needed"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Bony recontouring needed before seating?"
        },
        {
          "detail": "Apply firm gauze pressure to each extraction site and monitor until active bleeding is controlled.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Apply gauze pressure at extraction sites"
        },
        {
          "detail": "Does any site need sutures or an intra-socket hemostatic agent before the denture is seated?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "closure-needed",
              "label": "Place sutures and/or an intra-socket hemostatic agent to control bleeding or approximate soft tissue"
            },
            {
              "goto": "s9",
              "id": "pressure-sufficient",
              "label": "Bleeding is controlled with gauze pressure alone, no sutures or hemostatic agent needed"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Does any site need sutures or an intra-socket hemostatic agent before the denture is seated?"
        },
        {
          "detail": "Place sutures to approximate soft tissue over an alveoloplasty or extraction site where primary closure is planned, and/or place a hemostatic agent into any socket with ongoing oozing, confirming hemostasis before proceeding.\n\nWhy: Placing an intra-socket hemostatic agent or a suture is a licensed clinical act, distinct from the gauze-pressure first-aid step an assistant performs.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Place sutures and/or a hemostatic agent",
          "why": "Placing an intra-socket hemostatic agent or a suture is a licensed clinical act, distinct from the gauze-pressure first-aid step an assistant performs."
        },
        {
          "detail": "Seat the immediate denture over the extraction sites, checking it seats fully without excessive pressure on any single area, and adjust internal surfaces conservatively if needed.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Seat the immediate denture same-day"
        },
        {
          "detail": "Check bite contact with articulating paper and adjust for gross prematurities, understanding fine equilibration may wait for a later visit.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Check occlusion with the immediate denture seated"
        },
        {
          "detail": "Instruct the patient to leave the immediate denture in place for the first 24 hours as directed by the dentist to act as a surgical bandage, then follow normal removal/cleaning routine, and give standard post-extraction bleeding, swelling and pain guidance.\n\nWhy: Leaving an immediate denture seated initially helps control bleeding and swelling by splinting the extraction sites, which is a documented rationale specific to immediate dentures.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Give post-extraction and denture wear instructions",
          "why": "Leaving an immediate denture seated initially helps control bleeding and swelling by splinting the extraction sites, which is a documented rationale specific to immediate dentures."
        },
        {
          "detail": "Schedule a follow-up visit within the first week to check healing, sore spots, and whether a tissue conditioner or soft reline is needed as the ridges begin to remodel.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Schedule an early follow-up visit"
        },
        {
          "detail": "Tissue conditioner or soft reline needed at follow-up?",
          "forks": [
            {
              "advised": true,
              "goto": "s14",
              "id": "reline",
              "label": "Place tissue conditioner or soft reline to accommodate early ridge change"
            },
            {
              "goto": "s14",
              "id": "no-reline",
              "label": "Fit is stable, no reline needed yet"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "dentist",
          "title": "Tissue conditioner or soft reline needed at follow-up?"
        },
        {
          "detail": "Log the teeth extracted, hemostasis method, denture seating findings, and any reline placed in the chart.\n\nRecord: Procedure note covering extraction and immediate denture delivery",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Document extractions and immediate delivery"
        },
        {
          "detail": "Immediate denture delivered and follow-up scheduled",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Immediate denture delivered and follow-up scheduled"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Immediate denture — extraction sequence and same-day delivery — Remaining teeth are extracted and an immediate denture was pre-fabricated.",
      "title": "Immediate denture — extraction sequence and same-day delivery",
      "trigger": "Remaining teeth are extracted and an immediate denture was pre-fabricated",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "rpd-006",
      "kind": "clinical",
      "materials": [
        "diagnostic casts",
        "dental surveyor",
        "survey pencil / analysis rod",
        "laboratory prescription form for cast partial framework"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Place the diagnostic casts on the surveyor table and orient them to find a path of insertion that avoids interferences and gives favorable retention on the planned abutments.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Mount diagnostic casts on the surveyor"
        },
        {
          "detail": "Use the surveyor's analysis rod to trace the height of contour on each abutment tooth and mark the undercut areas that clasps will engage.\n\nWhy: The path of insertion chosen here determines where every clasp, rest, and guide plane goes; changing it later means re-surveying the whole case.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Identify and mark undercuts",
          "why": "The path of insertion chosen here determines where every clasp, rest, and guide plane goes; changing it later means re-surveying the whole case."
        },
        {
          "detail": "Mark planned rest seat locations on abutment teeth that will support the framework and direct occlusal forces along the long axis of each tooth.\n\nRecord: Rest seat locations noted on the design prescription",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Plan rest seat locations"
        },
        {
          "detail": "Identify proximal surfaces that will be prepared as parallel guide planes to control the path of insertion and provide reciprocation for clasps.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Plan guide plane surfaces"
        },
        {
          "detail": "Select clasp design per abutment",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "circumferential",
              "label": "Circumferential clasp on abutments with a favorable undercut location"
            },
            {
              "goto": "s6",
              "id": "bar-rpi",
              "label": "Bar-type or RPI clasp assembly where esthetics or undercut location favors it"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Select clasp design per abutment"
        },
        {
          "detail": "Draw the major and minor connector outline and denture-base coverage areas on the diagnostic cast, respecting tissue relief needs near soft-tissue-borne areas.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Outline the framework connector and coverage"
        },
        {
          "detail": "Mouth preparation needed before final impression?\n\nWhy: Reducing tooth structure for rest seats and guide planes is covered by the original RPD treatment-plan consent obtained before this design sequence begins; a separate consent gate is not inserted here because no new irreversible act beyond what was already consented to is introduced.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "prep-needed",
              "label": "Prepare rest seats and guide planes chairside before the final impression"
            },
            {
              "goto": "s8",
              "id": "no-prep",
              "label": "No tooth preparation needed, proceed to final impression as designed"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Mouth preparation needed before final impression?",
          "why": "Reducing tooth structure for rest seats and guide planes is covered by the original RPD treatment-plan consent obtained before this design sequence begins; a separate consent gate is not inserted here because no new irreversible act beyond what was already consented to is introduced."
        },
        {
          "detail": "The treating dentist reviews and confirms the clasp design, rest seat locations, guide planes, and any planned mouth preparation before the prescription is sent to the laboratory.\n\nWhy: The laboratory fabricates a rigid metal framework from this design; a design error caught after casting means remaking the framework rather than a chairside adjustment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the framework design before it is sent.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the framework design before it is sent",
          "why": "The laboratory fabricates a rigid metal framework from this design; a design error caught after casting means remaking the framework rather than a chairside adjustment."
        },
        {
          "detail": "Complete a written laboratory prescription with a drawn framework design (clasps, rests, connectors, relief areas) and path of insertion, and send it with the master impression.\n\nRecord: Laboratory work order with drawn framework design",
          "id": "s9",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send the design prescription to the laboratory"
        },
        {
          "detail": "Log the survey findings, clasp design, and any mouth preparation performed in the chart.\n\nRecord: Procedure note with framework design summary",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the design"
        },
        {
          "detail": "Framework design complete, prescription sent to laboratory",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Framework design complete, prescription sent to laboratory"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Removable partial denture design — survey, rests, guide planes, clasps — A partially edentulous patient chose a removable partial.",
      "title": "Removable partial denture design — survey, rests, guide planes, clasps",
      "trigger": "A partially edentulous patient chose a removable partial",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-patient",
      "id": "rpd-007",
      "kind": "clinical",
      "materials": [
        "cast metal framework",
        "articulating paper",
        "custom tray or impression material for altered-cast technique",
        "laboratory work order"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Seat the framework on the abutment teeth and check that rests, clasps, and connectors seat fully without rocking or binding.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Try in the cast framework"
        },
        {
          "detail": "Framework binds or rocks on seating?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "clean-seat",
              "label": "Framework seats fully and passively"
            },
            {
              "goto": "s11",
              "id": "adjust-needed",
              "label": "Framework binds or rocks, adjustment needed"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Framework binds or rocks on seating?"
        },
        {
          "detail": "Have the patient close and check for premature contacts on the framework's occlusal rests and connectors, adjusting as needed.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check occlusion with the framework in place"
        },
        {
          "detail": "Distal-extension case needing an altered cast or pickup impression?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "altered-cast",
              "label": "Take an altered-cast impression of the distal-extension area with the framework in place"
            },
            {
              "goto": "s5",
              "id": "tooth-borne",
              "label": "Fully tooth-borne case, proceed directly to final impression without altered cast"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Distal-extension case needing an altered cast or pickup impression?"
        },
        {
          "detail": "With the framework seated, take the final impression of the denture-base area(s) so the laboratory can process the acrylic saddle to the framework.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Take the final denture-base impression"
        },
        {
          "detail": "Disinfect the impression per infection-control guidance and ship it with the framework and a written work order for acrylic processing.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Disinfect the impression and ship to the laboratory"
        },
        {
          "detail": "The treating dentist confirms the framework seats passively, occlusion is acceptable, and the final impression is complete and free of voids before the case is sent for acrylic processing.\n\nWhy: Once processed to the framework, correcting a fit or occlusion problem means sectioning or remaking rather than a simple chairside adjustment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on framework fit before final shipment.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on framework fit before final shipment",
          "why": "Once processed to the framework, correcting a fit or occlusion problem means sectioning or remaking rather than a simple chairside adjustment."
        },
        {
          "detail": "Complete a written laboratory work order specifying acrylic processing to the framework and tooth arrangement instructions if not already set.\n\nRecord: Laboratory work order logged with case number and date sent",
          "id": "s8",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Send the case to the laboratory for processing"
        },
        {
          "detail": "Log framework fit findings, any adjustments made, and the impression technique used in the chart.\n\nRecord: Procedure note with framework try-in and impression details",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the visit"
        },
        {
          "detail": "Framework try-in complete, case sent for processing",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Framework try-in complete, case sent for processing"
        },
        {
          "detail": "Use disclosing spray or marking medium to find the exact contact causing the bind, and relieve only that contact on the framework or the tooth as appropriate.\n\nWhy: Forcing a binding framework to seat can fracture a clasp arm or crack the tooth it is bearing on; the bind is found and relieved before more force is applied.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Identify and relieve the binding contact",
          "why": "Forcing a binding framework to seat can fracture a clasp arm or crack the tooth it is bearing on; the bind is found and relieved before more force is applied."
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Partial denture framework try-in and altered-cast or pickup impression — The cast framework is returned from the lab.",
      "title": "Partial denture framework try-in and altered-cast or pickup impression",
      "trigger": "The cast framework is returned from the lab",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fabrication sequence — generic functional description"
          },
          "source": "Denture fabrication sequence — generic functional description — Practice policy — no published authority governs this step."
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "source": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "url": "https://www.govinfo.gov/content/pkg/CFR-2023-title29-vol6/pdf/CFR-2023-title29-vol6-sec1910-1200.pdf",
          "url_verified_at": "2026-09-14"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rpd-008",
      "kind": "clinical",
      "materials": [
        "pressure-indicating paste or spray",
        "acrylic adjustment burs and polishing wheels",
        "hand mirror for patient",
        "disclosing wax (optional)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Ask the patient to confirm they wore the denture for at least a few hours before this visit so the sore area is still visible on the tissue.\n\nWhy: If the denture was removed too far in advance, the pressure mark fades and the sore spot cannot be located reliably.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the denture was worn before the visit",
          "why": "If the denture was removed too far in advance, the pressure mark fades and the sore spot cannot be located reliably."
        },
        {
          "detail": "Denture removed too long before the visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "wear-more",
              "label": "Have the patient reseat and wear the denture in the waiting area before proceeding"
            },
            {
              "goto": "s3",
              "id": "proceed",
              "label": "Sore spot still visible, proceed directly"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Denture removed too long before the visit?"
        },
        {
          "detail": "Seat the denture and visually inspect the ridge and vestibule for redness, blanching, or ulceration corresponding to the patient's reported location.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Visually inspect the tissue with the denture seated"
        },
        {
          "detail": "Apply pressure-indicating paste or spray to the tissue side of the denture, reseat, and have the patient bite and function briefly to mark the exact high-pressure contact.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Apply pressure-indicating material to confirm the contact"
        },
        {
          "detail": "The treating dentist confirms the pressure-indicating mark corresponds to the patient's reported sore spot before any acrylic is removed.\n\nWhy: Acrylic removal is irreversible; confirming the mark against the patient's own report avoids relieving the wrong area.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the adjustment area before grinding.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the adjustment area before grinding",
          "why": "Acrylic removal is irreversible; confirming the mark against the patient's own report avoids relieving the wrong area."
        },
        {
          "detail": "Remove a conservative amount of acrylic at the marked contact using an adjustment bur, working in small increments and re-checking rather than removing all suspected material at once.\n\nWhy: Over-relieving an area can reduce retention or open a gap that creates a new sore spot elsewhere; small, verified reductions are safer.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Relieve the identified area",
          "why": "Over-relieving an area can reduce retention or open a gap that creates a new sore spot elsewhere; small, verified reductions are safer."
        },
        {
          "detail": "Reseat the denture, repeat the pressure-indicating check, and repeat adjustment until no high-pressure contact remains at the reported area.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Recheck fit and repeat if needed"
        },
        {
          "detail": "Polish the adjusted internal surface smooth so no rough acrylic edge is left against the tissue.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Polish the adjusted surface"
        },
        {
          "detail": "Patient comfortable after adjustment?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "resolved",
              "label": "Patient reports the area is no longer sore"
            },
            {
              "goto": "s10",
              "id": "recheck-visit",
              "label": "Discomfort persists, schedule a recheck visit"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Patient comfortable after adjustment?"
        },
        {
          "detail": "Log the location of the sore spot, the adjustment made, and the outcome of the comfort check in the chart.\n\nRecord: Procedure note with sore-spot location and adjustment details",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the sore-spot visit"
        },
        {
          "detail": "Sore spot addressed",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Sore spot addressed"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Denture sore-spot identification and adjustment — A patient reports a sore area after wearing a new or old denture.",
      "title": "Denture sore-spot identification and adjustment",
      "trigger": "A patient reports a sore area after wearing a new or old denture",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC guidance on disinfecting impressions and prostheses",
          "source": "CDC guidance on disinfecting impressions and prostheses",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "source": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        },
        {
          "kind": "generic",
          "label": "Reline vs rebase decision criteria — generic functional description of ridge-fit assessment and material choice by chair-time vs durability tradeoff — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Reline vs rebase decision criteria — generic functional description of ridge-fit assessment and material choice by chair-time vs durability tradeoff"
          },
          "source": "Reline vs rebase decision criteria — generic functional description of ridge-fit assessment and material choice by chair-time vs durability tradeoff — Practice policy — no published authority governs this step."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "rpd-009",
      "kind": "clinical",
      "materials": [
        "chairside soft reline material",
        "chairside hard (autopolymerizing acrylic) reline material",
        "pressure indicator paste",
        "tissue conditioner (interim option)",
        "final impression material for lab reline",
        "acrylic monomer SDS on file"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Seat the denture, check retention and stability by hand, and ask the patient when the looseness started and whether they have sore spots.\n\nWhy: Ridge resorption changes the fit of a denture base over time even when the teeth themselves are fine — confirming the complaint is fit, not occlusion, sets the right fix.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Assess the looseness complaint",
          "why": "Ridge resorption changes the fit of a denture base over time even when the teeth themselves are fine — confirming the complaint is fit, not occlusion, sets the right fix."
        },
        {
          "detail": "Examine the denture-bearing mucosa for redness, ulceration or hyperplastic tissue before proceeding.\n\nWhy: Relining over inflamed tissue can trap the problem under a new fitting surface instead of resolving it.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Check underlying tissue health",
          "why": "Relining over inflamed tissue can trap the problem under a new fitting surface instead of resolving it."
        },
        {
          "detail": "Is the tissue healthy enough to proceed?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "healthy",
              "label": "Tissue is healthy — proceed to reline/rebase evaluation"
            },
            {
              "goto": "s11",
              "id": "inflamed",
              "label": "Tissue is inflamed or irritated — treat first"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the tissue healthy enough to proceed?"
        },
        {
          "detail": "Apply pressure indicator paste to the intaglio surface, seat the denture, and identify areas of excess or insufficient contact.\n\nWhy: The paste pattern shows exactly where the base no longer matches the ridge, which decides whether a soft liner, hard chairside reline, or lab rebase is the right scope of fix.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Assess the extent of the ill-fit with pressure indicator paste",
          "why": "The paste pattern shows exactly where the base no longer matches the ridge, which decides whether a soft liner, hard chairside reline, or lab rebase is the right scope of fix."
        },
        {
          "detail": "Weigh how much of the base needs correcting, whether the patient needs a same-day fix, and how long the fit is expected to hold.",
          "forks": [
            {
              "goto": "s13",
              "id": "chairside-soft",
              "label": "Chairside soft reline — cushioning for sore or fragile ridges, shorter lifespan"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "chairside-hard",
              "label": "Chairside hard (autopolymerizing) reline — same-day, moderate ridge change"
            },
            {
              "goto": "s15",
              "id": "lab-reline",
              "label": "Laboratory reline or rebase — significant ridge change or full base replacement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Choose the reline approach"
        },
        {
          "detail": "The treating dentist confirms the hard-reline approach and the intaglio areas to relieve before any acrylic is trimmed from the denture base.\n\nWhy: Trimming the intaglio surface is irreversible; a licensed clinician confirms the plan before it begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the plan before the chairside hard reline.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the plan before the chairside hard reline",
          "why": "Trimming the intaglio surface is irreversible; a licensed clinician confirms the plan before it begins."
        },
        {
          "detail": "Relieve the intaglio surface, apply the autopolymerizing acrylic reline material per manufacturer instructions, seat the denture with the patient biting into normal occlusion, and allow it to cure.\n\nWhy: A same-day hard reline restores accurate contact with the current ridge shape without a lab turnaround.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Place the chairside hard reline",
          "why": "A same-day hard reline restores accurate contact with the current ridge shape without a lab turnaround."
        },
        {
          "detail": "Verify the patient closes into their prior occlusal contacts, check for any pressure spots, and adjust the borders or occlusion as needed.\n\nWhy: Adding material to the base can shift occlusal contact slightly — checking before the patient leaves avoids a callback for a bite adjustment.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Check occlusion and fit after relining",
          "why": "Adding material to the base can shift occlusal contact slightly — checking before the patient leaves avoids a callback for a bite adjustment."
        },
        {
          "detail": "Log the date, reline type performed (chairside soft, chairside hard, or lab reline/rebase), tissue findings, and any adjustments made in the patient chart.\n\nRecord: Chart: date, reline type performed, tissue findings, adjustments made.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Record the reline in the chart"
        },
        {
          "detail": "Reline complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Reline complete"
        },
        {
          "detail": "Advise the patient on denture hygiene and out-of-mouth rest at night, schedule a re-check, and defer the reline until tissue is healthy.\n\nWhy: Fitting a new base to inflamed tissue bakes in an inaccurate fit once the tissue recovers.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Route to denture stomatitis management before relining",
          "why": "Fitting a new base to inflamed tissue bakes in an inaccurate fit once the tissue recovers."
        },
        {
          "detail": "Reline deferred pending tissue treatment",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Reline deferred pending tissue treatment"
        },
        {
          "detail": "The treating dentist confirms the soft-liner approach and the intaglio areas to relieve before any acrylic is trimmed from the denture base.\n\nWhy: Trimming the intaglio surface is irreversible; a licensed clinician confirms the plan before it begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the plan before the chairside soft reline.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the plan before the chairside soft reline",
          "why": "Trimming the intaglio surface is irreversible; a licensed clinician confirms the plan before it begins."
        },
        {
          "detail": "Trim and relieve the intaglio surface as needed, mix and apply the soft liner per its instructions for use, seat the denture, and have the patient hold light closure until set.\n\nWhy: A soft liner is chosen for comfort over ridges that cannot tolerate a rigid base yet, at the cost of shorter service life than a hard reline.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Place the chairside soft liner",
          "why": "A soft liner is chosen for comfort over ridges that cannot tolerate a rigid base yet, at the cost of shorter service life than a hard reline."
        },
        {
          "detail": "Border-mold and take a final impression inside the existing denture base (or a new custom tray for a full rebase), then complete a written lab work order per state authorization requirements.\n\nWhy: A lab reline or rebase captures a more accurate final impression than chairside material allows, appropriate when the ridge change is extensive.",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Take a final wash impression for the lab",
          "why": "A lab reline or rebase captures a more accurate final impression than chairside material allows, appropriate when the ridge change is extensive."
        },
        {
          "detail": "The treating dentist reviews and signs the written work order (tooth/arch, material, shade if teeth are being reset, due date) before it ships to the lab.\n\nWhy: A lab work order is a legal authorization to fabricate under state dental practice acts; it cannot be sent unsigned.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the lab work order.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s16",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the lab work order",
          "why": "A lab work order is a legal authorization to fabricate under state dental practice acts; it cannot be sent unsigned."
        },
        {
          "detail": "Package the impression or scan file, the signed work order, and any shade notes; log the case as sent and set an expected return date.",
          "id": "s17",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Ship the case to the laboratory"
        },
        {
          "detail": "Book a return visit for the patient once the lab case is due back, and confirm the case has arrived before the appointment.",
          "id": "s18",
          "kind": "step",
          "role": "assistant",
          "title": "Schedule the relined/rebased denture delivery visit"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Reline or rebase decision — chairside soft, chairside hard or lab reline — A denture has become loose from ridge resorption.",
      "title": "Reline or rebase decision — chairside soft, chairside hard or lab reline",
      "trigger": "A denture has become loose from ridge resorption",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC guidance on disinfecting impressions and prostheses",
          "source": "CDC guidance on disinfecting impressions and prostheses",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "source": "OSHA 29 CFR 1910.1200 (acrylic monomer SDS)",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        },
        {
          "kind": "generic",
          "label": "Denture fracture and tooth-loss repair triage — generic functional description of chairside-vs-lab repair scope — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Denture fracture and tooth-loss repair triage — generic functional description of chairside-vs-lab repair scope"
          },
          "source": "Denture fracture and tooth-loss repair triage — generic functional description of chairside-vs-lab repair scope — Practice policy — no published authority governs this step."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rpd-010",
      "kind": "clinical",
      "materials": [
        "repair acrylic (autopolymerizing)",
        "replacement denture tooth stock or matching shade set",
        "wire or mesh reinforcement for clasp/fracture repair",
        "denture repair impression/model material",
        "disinfectant for the returned appliance"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Collect all pieces from the patient in a bag or container, note the patient's name and the date received on a repair case slip, and disinfect the appliance per office infection-control procedure before it goes to the treatment area.\n\nWhy: A denture that has been in a patient's mouth is treated as a contaminated item until disinfected, and missing pieces make an accurate repair impossible.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive and log the broken denture",
          "why": "A denture that has been in a patient's mouth is treated as a contaminated item until disinfected, and missing pieces make an accurate repair impossible."
        },
        {
          "detail": "Examine the appliance to determine whether the fracture is a clean midline break, a broken clasp, a lost or chipped tooth, or multiple pieces, and check that all fragments are present and fit together.\n\nWhy: The repair method and whether it can be done chairside both depend on damage type and whether the pieces reassemble cleanly.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Assess the type and extent of damage",
          "why": "The repair method and whether it can be done chairside both depend on damage type and whether the pieces reassemble cleanly."
        },
        {
          "detail": "What kind of repair is needed?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "simple-fracture",
              "label": "Clean base fracture, pieces reassemble — chairside repair"
            },
            {
              "goto": "s8",
              "id": "tooth-or-clasp",
              "label": "Lost tooth or broken clasp needing a matched part — lab repair"
            },
            {
              "goto": "s13",
              "id": "unrepairable",
              "label": "Multiple missing pieces or base too damaged to repair"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "What kind of repair is needed?"
        },
        {
          "detail": "Align and index the fragments, apply autopolymerizing repair acrylic per its instructions for use, and allow it to cure before trimming and polishing the repaired area.\n\nWhy: A clean fracture that reassembles accurately can usually be repaired the same visit without sending the case out. This branch does not carry a separate pre-ship licensed-signoff gate because the dentist personally performs and directly inspects the repair in one continuous chairside visit — unlike the lab-repair branch, nothing leaves the office before a licensed clinician has seen the finished result at fit_check.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Perform the chairside acrylic repair",
          "why": "A clean fracture that reassembles accurately can usually be repaired the same visit without sending the case out. This branch does not carry a separate pre-ship licensed-signoff gate because the dentist personally performs and directly inspects the repair in one continuous chairside visit — unlike the lab-repair branch, nothing leaves the office before a licensed clinician has seen the finished result at fit_check."
        },
        {
          "detail": "Seat the repaired appliance, check that it seats fully and comfortably, and verify occlusal contacts have not shifted.\n\nWhy: A repair that changes the base contour even slightly can create a new pressure spot the patient did not have before.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Verify fit and occlusion after repair",
          "why": "A repair that changes the base contour even slightly can create a new pressure spot the patient did not have before."
        },
        {
          "detail": "Log the date received, damage type, repair method (chairside or lab), and fit-check outcome in the patient chart and close out the repair case slip.\n\nRecord: Chart: date received, damage type, repair method, fit-check outcome; repair case slip closed out.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Record the repair in the chart"
        },
        {
          "detail": "Repair complete and returned to patient",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Repair complete and returned to patient"
        },
        {
          "detail": "Take an impression of the denture in its current state (or send the appliance itself if the lab requests it) along with a written work order describing the repair needed and the tooth shade if a tooth is being replaced.\n\nWhy: Adding a matched replacement tooth or rebuilding a clasp needs lab stock and equipment not available chairside.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Take an impression or model of the current appliance for the lab",
          "why": "Adding a matched replacement tooth or rebuilding a clasp needs lab stock and equipment not available chairside."
        },
        {
          "detail": "The treating dentist reviews and signs the written work order describing exactly what the lab is to repair before the appliance and order ship.\n\nWhy: A lab work order is a legal authorization to fabricate/repair under state dental practice acts and cannot be sent unsigned.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the repair work order.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the repair work order",
          "why": "A lab work order is a legal authorization to fabricate/repair under state dental practice acts and cannot be sent unsigned."
        },
        {
          "detail": "Does the patient need a loaner or interim while the repair is out?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "no-loaner",
              "label": "Patient can manage without the appliance for the turnaround"
            },
            {
              "goto": "s15",
              "id": "needs-loaner",
              "label": "Patient needs an interim solution"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient need a loaner or interim while the repair is out?"
        },
        {
          "detail": "Package the appliance (or impression), the signed work order, and shade notes; log the case as sent with an expected return date and notify the patient of the estimated turnaround.",
          "id": "s11",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Ship the appliance and work order to the laboratory"
        },
        {
          "detail": "Book a short visit for the patient to pick up and try in the repaired appliance once the lab case is back, confirming arrival before the appointment.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule the return-of-appliance visit"
        },
        {
          "detail": "Explain to the patient that the appliance is beyond repair and discuss options for a new denture, referencing the complete or partial denture protocol as applicable.\n\nWhy: A base too fragmented or degraded to repair reliably will fail again quickly if patched, so the honest recommendation is a remake.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss full replacement rather than repair",
          "why": "A base too fragmented or degraded to repair reliably will fail again quickly if patched, so the honest recommendation is a remake."
        },
        {
          "detail": "Replacement discussion documented, repair not performed",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Replacement discussion documented, repair not performed"
        },
        {
          "detail": "Record the patient's request for an interim option and have the dentist determine whether a spare appliance, a rush turnaround, or another interim solution is appropriate.\n\nWhy: Being without a denture affects a patient's eating and speaking, so a documented plan avoids the request getting lost between visits.",
          "id": "s15",
          "kind": "step",
          "role": "front-desk",
          "title": "Note the interim need and coordinate with the dentist",
          "why": "Being without a denture affects a patient's eating and speaking, so a documented plan avoids the request getting lost between visits."
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Denture repair — fracture, tooth added, clasp repair — A patient brings a broken denture or one with a lost tooth.",
      "title": "Denture repair — fracture, tooth added, clasp repair",
      "trigger": "A patient brings a broken denture or one with a lost tooth",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC guidance on disinfecting impressions and prostheses",
          "source": "CDC guidance on disinfecting impressions and prostheses",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "generic",
          "label": "Denture-related stomatitis assessment and hygiene counseling — generic functional description of standard-of-care denture hygiene guidance",
          "source": "Denture-related stomatitis assessment and hygiene counseling — generic functional description of standard-of-care denture hygiene guidance"
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rpd-011",
      "kind": "clinical",
      "materials": [
        "denture cleaning brush",
        "non-abrasive denture cleanser",
        "topical antifungal (if prescribed)",
        "patient hygiene handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Remove the denture and examine the underlying mucosa for redness, texture change, or papillary hyperplasia, noting whether the pattern matches the denture-bearing area.\n\nWhy: Erythema confined to the denture-bearing surface, matching the appliance's outline, points to denture-related inflammation rather than a systemic or unrelated oral condition.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify and assess the erythematous area",
          "why": "Erythema confined to the denture-bearing surface, matching the appliance's outline, points to denture-related inflammation rather than a systemic or unrelated oral condition."
        },
        {
          "detail": "Ask whether the patient sleeps in the denture, how it is cleaned and how often, and whether a cleanser or plain water/brush is used.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Ask about denture wear and cleaning habits"
        },
        {
          "detail": "Examine the intaglio surface of the denture for plaque, calculus, or a porous/roughened acrylic surface, and check whether the appliance still fits well or is contributing to trauma.\n\nWhy: A poorly fitting or unclean denture is a common contributing cause, not just the tissue reaction alone — fixing the tissue without addressing the appliance invites recurrence.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check the denture itself for fit and cleanliness",
          "why": "A poorly fitting or unclean denture is a common contributing cause, not just the tissue reaction alone — fixing the tissue without addressing the appliance invites recurrence."
        },
        {
          "detail": "Is hygiene counseling sufficient, or is medication indicated?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "hygiene-only",
              "label": "Mild inflammation, likely hygiene-related — counseling and re-check"
            },
            {
              "goto": "s13",
              "id": "medication-indicated",
              "label": "Persistent or more severe inflammation — consider topical antifungal"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is hygiene counseling sufficient, or is medication indicated?"
        },
        {
          "detail": "Instruct the patient to remove and brush the denture daily with a non-abrasive cleanser, soak it in a denture-cleaning solution or plain water (never hot water) overnight, and leave it out of the mouth while sleeping.\n\nWhy: Nightly removal lets the tissue rest and reduces the moist, covered environment that favors the inflammation — the single change with the most evidence behind it.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Counsel the patient on denture hygiene",
          "why": "Nightly removal lets the tissue rest and reduces the moist, covered environment that favors the inflammation — the single change with the most evidence behind it."
        },
        {
          "detail": "Give the patient a take-home handout summarizing cleaning steps, nightly removal, and when to call the office if symptoms worsen or persist.\n\nWhy: Written instructions reduce the chance oral-only counseling is forgotten once the patient leaves.",
          "id": "s6",
          "kind": "step",
          "role": "hygienist",
          "title": "Provide a written hygiene handout",
          "why": "Written instructions reduce the chance oral-only counseling is forgotten once the patient leaves."
        },
        {
          "detail": "Book a short follow-up visit, typically within 2–4 weeks, to confirm the tissue has improved.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a follow-up re-check"
        },
        {
          "detail": "Document tissue findings, hygiene habits discussed, counseling or medication provided, and the follow-up interval in the patient chart.\n\nRecord: Tissue findings, hygiene habits discussed, counseling or medication provided, and the follow-up interval are documented in the patient chart.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Record findings and plan in the chart"
        },
        {
          "detail": "Hold the case open until the patient returns for the follow-up re-check, typically 2–4 weeks out.",
          "id": "s9",
          "kind": "timer",
          "role": "front-desk",
          "timer_seconds": 1814400,
          "title": "Wait for the scheduled follow-up visit"
        },
        {
          "detail": "Remove the denture and compare the tissue appearance to the initial exam findings.\n\nWhy: Confirming resolution (or lack of it) closes the loop and flags cases that need escalation rather than assuming the counseling worked.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Re-examine the tissue at follow-up",
          "why": "Confirming resolution (or lack of it) closes the loop and flags cases that need escalation rather than assuming the counseling worked."
        },
        {
          "detail": "Has the tissue improved?",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "resolved",
              "label": "Tissue has returned to normal appearance"
            },
            {
              "goto": "s14",
              "id": "not-resolved",
              "label": "Tissue has not improved or has worsened"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Has the tissue improved?"
        },
        {
          "detail": "Stomatitis resolved",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Stomatitis resolved"
        },
        {
          "detail": "The treating dentist confirms the diagnosis and prescribes a topical antifungal, documenting the indication in the chart before the prescription is sent.\n\nWhy: Prescribing medication is a licensed clinical decision that cannot be automated or delegated without the treating dentist's sign-off.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs off on the topical antifungal prescription.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs off on the topical antifungal prescription",
          "why": "Prescribing medication is a licensed clinical decision that cannot be automated or delegated without the treating dentist's sign-off."
        },
        {
          "detail": "Consider a specialist referral or biopsy if the tissue does not respond to standard denture-hygiene and antifungal management.\n\nWhy: Persistent inflammation despite standard management can indicate a different or additional condition needing further workup.",
          "id": "s14",
          "kind": "step",
          "role": "dentist",
          "title": "Escalate for further evaluation",
          "why": "Persistent inflammation despite standard management can indicate a different or additional condition needing further workup."
        },
        {
          "detail": "Escalated for further evaluation",
          "id": "s15",
          "kind": "step",
          "role": "dentist",
          "title": "Escalated for further evaluation"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Denture stomatitis and denture hygiene management — Erythema under a denture base, or a patient who sleeps in dentures.",
      "title": "Denture stomatitis and denture hygiene management",
      "trigger": "Erythema under a denture base, or a patient who sleeps in dentures",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC guidance on disinfecting impressions and prostheses",
          "source": "CDC guidance on disinfecting impressions and prostheses",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "statute",
          "label": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "source": "CA B&P §1626(e) (16 CCR §1063) written laboratory work-order requirements",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1626."
        },
        {
          "kind": "generic",
          "label": "Interim removable tooth replacement (flipper / vacuum-formed retainer with tooth) — generic functional description of same-day vs lab-fabricated interim options — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Interim removable tooth replacement (flipper / vacuum-formed retainer with tooth) — generic functional description of same-day vs lab-fabricated interim options"
          },
          "source": "Interim removable tooth replacement (flipper / vacuum-formed retainer with tooth) — generic functional description of same-day vs lab-fabricated interim options — Practice policy — no published authority governs this step."
        }
      ],
      "class": "prosthodontics-fixed-removable",
      "department": "clinical",
      "duration_min": 40,
      "frequency": "as-needed",
      "id": "rpd-012",
      "kind": "clinical",
      "materials": [
        "alginate or digital scan for impression",
        "vacuum-formed thermoplastic sheet (for same-day option)",
        "denture tooth matching shade",
        "cold-cure acrylic (flipper fabrication)",
        "articulating paper"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "lab-liaison"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Confirm which tooth was lost or is being extracted, and discuss with the patient whether an immediate esthetic interim is wanted before a permanent replacement (implant, bridge, or partial) is planned.\n\nWhy: An interim is a stopgap, not the final treatment — setting that expectation up front avoids confusion later about what was actually delivered.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the need for an interim esthetic replacement",
          "why": "An interim is a stopgap, not the final treatment — setting that expectation up front avoids confusion later about what was actually delivered."
        },
        {
          "detail": "Confirm the patient or caregiver understands the interim appliance's temporary nature, its wear limitations (avoiding hard/sticky foods, possible fragility), and the agreed plan and timeline for permanent replacement, before fabrication begins.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm patient consent for the interim appliance.",
            "type": "safety"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm patient consent for the interim appliance"
        },
        {
          "detail": "Is same-day chairside fabrication appropriate, or is a lab-made flipper needed?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "same-day",
              "label": "Same-day vacuum-formed interim — single tooth, simple case"
            },
            {
              "goto": "s12",
              "id": "lab-flipper",
              "label": "Lab-fabricated flipper — multiple teeth or more durable interim needed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is same-day chairside fabrication appropriate, or is a lab-made flipper needed?"
        },
        {
          "detail": "Take an alginate impression or digital scan of the arch, ideally before extraction so the tooth position is captured, or immediately after if the tooth is already lost.\n\nWhy: Capturing the pre-extraction tooth position gives the most natural-looking replacement contour.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Take an impression or scan before/after the extraction",
          "why": "Capturing the pre-extraction tooth position gives the most natural-looking replacement contour."
        },
        {
          "detail": "Compare denture tooth stock against the adjacent natural teeth in daylight-equivalent lighting and select the closest shade.\n\nWhy: A visibly mismatched interim tooth defeats the esthetic purpose of providing one.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Select a matching denture tooth shade",
          "why": "A visibly mismatched interim tooth defeats the esthetic purpose of providing one."
        },
        {
          "detail": "Form the thermoplastic sheet over a model with the extraction site blocked out, position and bond the matched denture tooth into the void, and trim the appliance to fit the arch.\n\nWhy: The vacuum-formed shell holds the replacement tooth in place without clasps, making it fast to fabricate and comfortable for a short-term interim.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Fabricate the vacuum-formed interim with the replacement tooth",
          "why": "The vacuum-formed shell holds the replacement tooth in place without clasps, making it fast to fabricate and comfortable for a short-term interim."
        },
        {
          "detail": "Seat the appliance, check retention, esthetics, and occlusal contact with articulating paper, and adjust as needed so the patient can close comfortably.\n\nWhy: An interim that interferes with the bite will be uncomfortable enough that the patient stops wearing it, defeating its purpose.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Try in and adjust the interim appliance",
          "why": "An interim that interferes with the bite will be uncomfortable enough that the patient stops wearing it, defeating its purpose."
        },
        {
          "detail": "Instruct the patient on insertion and removal, cleaning the appliance, avoiding hard/sticky foods, and removing it at night if advised.\n\nWhy: An interim appliance the patient does not know how to care for is more likely to break or contribute to tissue irritation.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Give the patient wear and care instructions",
          "why": "An interim appliance the patient does not know how to care for is more likely to break or contribute to tissue irritation."
        },
        {
          "detail": "Confirm with the patient the intended path to permanent replacement (implant, bridge, or partial denture) and the expected timeline for the interim.\n\nWhy: Without a stated timeline, an interim appliance risks becoming the de facto permanent solution by default.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Discuss the plan and timeline for permanent replacement",
          "why": "Without a stated timeline, an interim appliance risks becoming the de facto permanent solution by default."
        },
        {
          "detail": "Log the tooth replaced, fabrication method (same-day vacuum-formed or lab flipper), delivery date, and the discussed permanent-replacement plan in the patient chart.\n\nRecord: Chart: tooth replaced, fabrication method, delivery date, permanent-replacement plan.",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Record the interim delivery in the chart"
        },
        {
          "detail": "Interim appliance delivered",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Interim appliance delivered"
        },
        {
          "detail": "Take a final impression or scan of the arch, select a matching shade, and complete a written lab work order describing the teeth to be replaced and the clasp design if any.\n\nWhy: A multi-tooth or clasp-retained flipper needs lab fabrication for accuracy and durability that chairside vacuum-forming cannot match.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Take a final impression and complete the lab work order",
          "why": "A multi-tooth or clasp-retained flipper needs lab fabrication for accuracy and durability that chairside vacuum-forming cannot match."
        },
        {
          "detail": "The treating dentist reviews and signs the written work order before it ships to the lab.\n\nWhy: A lab work order is a legal authorization to fabricate under state dental practice acts and cannot be sent unsigned.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs the flipper work order.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s13",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs the flipper work order",
          "why": "A lab work order is a legal authorization to fabricate under state dental practice acts and cannot be sent unsigned."
        },
        {
          "detail": "Package the impression, signed work order, and shade notes; log the case as sent and schedule the patient's delivery visit for when the lab case is due back.",
          "id": "s14",
          "kind": "step",
          "role": "lab-liaison",
          "title": "Ship the case to the laboratory and schedule delivery"
        }
      ],
      "subclass": "removable-prosthodontics",
      "summary": "Interim flipper or vacuum-formed tooth replacement — An anterior tooth is lost and the patient needs an immediate esthetic interim.",
      "title": "Interim flipper or vacuum-formed tooth replacement",
      "trigger": "An anterior tooth is lost and the patient needs an immediate esthetic interim",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "source": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        },
        {
          "kind": "generic",
          "label": "For the recall due-list pull and outreach cadence — no scheduling-consultancy system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for the recall due-list pull and outreach cadence — no scheduling-consultancy system reproduced"
          },
          "source": "For the recall due-list pull and outreach cadence — no scheduling-consultancy system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 120,
      "frequency": "monthly",
      "id": "rrr-001",
      "kind": "operational",
      "materials": [
        "practice management system recall report",
        "text/email outreach template set",
        "phone list with consent-to-contact flags",
        "outreach tracking sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Export every patient whose recall interval falls due this calendar month who has no appointment currently booked, from the practice management system's recall report.\n\nWhy: A monthly pull catches everyone before the due date slips into an overdue bucket that is harder to reactivate.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull the recall-due report for the month",
          "why": "A monthly pull catches everyone before the due date slips into an overdue bucket that is harder to reactivate."
        },
        {
          "detail": "Remove or flag-for-mail-only any patient marked opted-out of text/call outreach; TCPA and CAN-SPAM require honoring channel-level consent.\n\nWhy: Contacting a patient on a channel they opted out of is a statutory violation, not just a courtesy miss.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Filter the list against consent-to-contact flags",
          "why": "Contacting a patient on a channel they opted out of is a statutory violation, not just a courtesy miss."
        },
        {
          "detail": "Sort by due date ascending as the primary key; among patients due in the same week, prioritize a clean attendance history over a no-show/cancel history for same-day contact.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Sort the list by due date and prior no-show/cancel history"
        },
        {
          "detail": "Use the approved recall message template to text or email each consented patient, inviting them to self-schedule or reply for a call back.\n\nWhy: Text/email first is lower-cost and faster than calling every name on the list.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Send first-wave outreach (text or email per template)",
          "why": "Text/email first is lower-cost and faster than calling every name on the list."
        },
        {
          "detail": "Place an outbound call offering two or three specific open times; log the outcome (scheduled, callback requested, no answer, declined) on the tracking sheet.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Call patients who do not respond within 3 business days"
        },
        {
          "detail": "Write the date of run, list size, number contacted, number scheduled, channel used per contact, and any opt-outs recorded, onto the tracking sheet.\n\nRecord: Date of run, list size, number contacted, number scheduled, channel used per contact, and any opt-outs recorded.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the run's outcomes on the tracking sheet"
        },
        {
          "detail": "Any patient not scheduled after this run moves into the unscheduled-recall outreach cadence (rrr-002) rather than being dropped.\n\nWhy: A single monthly pass is not enough contact attempts to convert most of the list.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Carry unresolved names into the 30/60/90 cadence",
          "why": "A single monthly pass is not enough contact attempts to convert most of the list."
        },
        {
          "detail": "Monthly recall run complete",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Monthly recall run complete"
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Monthly recall due list run and outreach — First business day of each month — patients due this month without an appointment.",
      "title": "Monthly recall due list run and outreach",
      "trigger": "First business day of each month — patients due this month without an appointment",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "source": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        },
        {
          "kind": "generic",
          "label": "For the 30/60/90-day escalating cadence — no scheduling-consultancy system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for the 30/60/90-day escalating cadence — no scheduling-consultancy system reproduced"
          },
          "source": "For the 30/60/90-day escalating cadence — no scheduling-consultancy system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rrr-002",
      "kind": "operational",
      "materials": [
        "practice management system unscheduled-recall report",
        "text/call/letter template set at 30/60/90 days",
        "outreach tracking sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull every patient who is now 30, 60 or 90 days past their recall due date with still no appointment booked.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Run the unscheduled-recall report"
        },
        {
          "detail": "Which threshold is this patient at?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "d30",
              "label": "30 days overdue — send a text"
            },
            {
              "goto": "s6",
              "id": "d60",
              "label": "60 days overdue — place a call"
            },
            {
              "goto": "s7",
              "id": "d90",
              "label": "90 days overdue — send a letter and route to reactivation"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Which threshold is this patient at?"
        },
        {
          "detail": "Text the consented patient a brief reminder that their recall is due and an easy self-schedule link or reply-to-book prompt.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the 30-day text reminder"
        },
        {
          "detail": "Write the threshold reached, channel used, date, and outcome onto the tracking sheet for this patient.\n\nRecord: Threshold reached, channel used, date, and outcome (scheduled, no response, declined, bad contact info).",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the touch on the tracking sheet"
        },
        {
          "detail": "Cadence touch complete for this threshold",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Cadence touch complete for this threshold"
        },
        {
          "detail": "Call the patient directly, offer two specific open times, and note the outcome; if unreachable, leave a voicemail per the approved script.\n\nWhy: A phone call carries more weight than a second text once a text has already gone unanswered.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Place the 60-day outbound call",
          "why": "A phone call carries more weight than a second text once a text has already gone unanswered."
        },
        {
          "detail": "Mail the approved recall letter and add the patient to the quarterly inactive-patient list for the reactivation protocol (rrr-003).\n\nWhy: At 90 days a patient is treated as at risk of lapsing rather than merely late, so a different channel and a different owner engage.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the 90-day letter and flag for reactivation",
          "why": "At 90 days a patient is treated as at risk of lapsing rather than merely late, so a different channel and a different owner engage."
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Unscheduled recall outreach cadence (text, call, letter) — A patient is due and unscheduled at 30, 60 and 90 days.",
      "title": "Unscheduled recall outreach cadence (text, call, letter)",
      "trigger": "A patient is due and unscheduled at 30, 60 and 90 days",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "source": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        },
        {
          "kind": "regulation",
          "label": "FTC Endorsement Guides 16 CFR Part 255 — no incentivized or gated reviews",
          "source": "FTC Endorsement Guides 16 CFR Part 255 — no incentivized or gated reviews",
          "url": "https://www.ecfr.gov/current/title-16/part-255"
        },
        {
          "kind": "generic",
          "label": "For the quarterly reactivation campaign — no marketing-consultancy system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for the quarterly reactivation campaign — no marketing-consultancy system reproduced"
          },
          "source": "For the quarterly reactivation campaign — no marketing-consultancy system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 180,
      "frequency": "quarterly",
      "id": "rrr-003",
      "kind": "operational",
      "materials": [
        "practice management system inactive-patient report (18+ months no visit)",
        "reactivation letter/email/postcard templates",
        "reactivation offer policy (if any)",
        "outreach tracking sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "marketing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pull every patient with no completed visit in 18 or more months and no scheduled future appointment.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the quarterly inactive-patient report"
        },
        {
          "detail": "Remove patients already flagged deceased, moved out of area, or with previously bounced contact info per the database-hygiene protocol (rrr-008) before spending outreach effort on them.\n\nWhy: Mailing or calling a dead or invalid contact wastes the campaign budget and can create a bad-data feedback loop.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Scrub the list against database hygiene flags",
          "why": "Mailing or calling a dead or invalid contact wastes the campaign budget and can create a bad-data feedback loop."
        },
        {
          "detail": "Group patients into bands (18-24mo, 24-36mo, 36mo+) so the message and channel can be matched to how cold the relationship is.",
          "id": "s3",
          "kind": "step",
          "role": "marketing",
          "title": "Segment the list by inactivity length and last treatment type"
        },
        {
          "detail": "Does the campaign include a reactivation offer?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-offer",
              "label": "No offer — plain re-engagement message"
            },
            {
              "goto": "s11",
              "id": "offer",
              "label": "Include a defined reactivation offer"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the campaign include a reactivation offer?"
        },
        {
          "detail": "Deploy the approved letter/email/postcard per segment; include a clear, low-friction way to schedule (phone number, link, or reply).",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Send the segmented reactivation campaign"
        },
        {
          "detail": "Call anyone who replies within 5 business days, plus a spot-check sample of non-responders in the 18-24 month band.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Follow up by phone on responders and a sample of non-responders"
        },
        {
          "detail": "Did the patient schedule?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "Scheduled — route through re-establishment"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "Not scheduled after this quarter's campaign"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the patient schedule?"
        },
        {
          "detail": "Because the gap exceeds the practice's records/comprehensive-exam threshold, route the scheduled visit through rrr-004 (returning patient after long absence) rather than a routine hygiene slot.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the returning-patient re-establishment protocol"
        },
        {
          "detail": "Write the list size, segment breakdown, channel used, response count, scheduled count, and campaign cost onto the tracking sheet.\n\nRecord: List size, segment breakdown, channel used, response count, scheduled count, and cost if a paid offer or mailing was used.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log campaign results"
        },
        {
          "detail": "Quarterly reactivation campaign complete",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Quarterly reactivation campaign complete"
        },
        {
          "detail": "Confirm any discount or incentive language does not condition it on posting a review (FTC Endorsement Guides 16 CFR Part 255) and is consistent across all recipients in the same segment.\n\nWhy: A gated or incentivized-review offer is a specific, enforced FTC violation, not a style choice.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Review the offer for compliance before it ships.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "office-manager",
          "title": "Review the offer for compliance before it ships",
          "why": "A gated or incentivized-review offer is a specific, enforced FTC violation, not a style choice."
        },
        {
          "detail": "Patients still unresponsive after two consecutive quarterly campaigns are flagged for a reduced-frequency annual-only outreach rather than every quarter.\n\nWhy: Repeated unanswered outreach at full frequency has diminishing returns and can read as harassment.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Mark unresponsive patients for the next campaign cycle",
          "why": "Repeated unanswered outreach at full frequency has diminishing returns and can read as harassment."
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Reactivation of patients inactive 18 months or more — Quarterly inactive-patient list run.",
      "title": "Reactivation of patients inactive 18 months or more",
      "trigger": "Quarterly inactive-patient list run",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — new-form and appointment-confirmation texts/emails sent to the returning patient",
          "source": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — new-form and appointment-confirmation texts/emails sent to the returning patient",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        },
        {
          "kind": "public_domain",
          "label": "ADA/FDA \"Dental Radiographic Examinations: Selection Criteria for Patients\" — radiograph type and extent is an individualized clinical judgment made by the treating dentist, not a fixed scheduling default",
          "source": "ADA/FDA \"Dental Radiographic Examinations: Selection Criteria for Patients\" — radiograph type and extent is an individualized clinical judgment made by the treating dentist, not a fixed scheduling default",
          "url": "https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/dental-radiographic-examinations"
        },
        {
          "kind": "generic",
          "label": "For treating a long-absent patient's return as a new-patient re-establishment (updated history, new consents, comprehensive exam) — no scheduling-consultancy system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for treating a long-absent patient's return as a new-patient re-establishment (updated history, new consents, comprehensive exam) — no scheduling-consultancy system reproduced"
          },
          "source": "For treating a long-absent patient's return as a new-patient re-establishment (updated history, new consents, comprehensive exam) — no scheduling-consultancy system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rrr-004",
      "kind": "operational",
      "materials": [
        "new-patient intake and health history forms",
        "records-request template (if prior records are elsewhere)",
        "practice management system re-activation flag"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "scheduler",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the practice management system for the last completed visit date; a gap of three or more years routes to this protocol instead of a routine recall booking.\n\nWhy: Health status, insurance, contact info and clinical findings are all presumed stale after this long, so the visit needs to be treated as new rather than continuing.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the length of the absence when the patient calls",
          "why": "Health status, insurance, contact info and clinical findings are all presumed stale after this long, so the visit needs to be treated as new rather than continuing."
        },
        {
          "detail": "Is the gap three years or more?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "Three years or more — re-establish as new"
            },
            {
              "goto": "s10",
              "id": "no",
              "label": "Under three years — route to standard recall booking"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the gap three years or more?"
        },
        {
          "detail": "Schedule the return visit in the comprehensive-exam block length, with a new health history review built into the visit and imaging determined at the visit per the treating dentist's radiographic selection criteria (ADA/FDA guidance), not a fixed imaging order set by the scheduler.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Book a comprehensive exam appointment, not a routine hygiene slot"
        },
        {
          "detail": "Send the full new-patient intake, health history, and consent forms ahead of the visit rather than relying on the old chart.\n\nWhy: Medications, medical conditions, insurance and emergency contacts routinely change over a multi-year gap.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Send updated intake and health history forms",
          "why": "Medications, medical conditions, insurance and emergency contacts routinely change over a multi-year gap."
        },
        {
          "detail": "Is the prior chart still retained by this practice?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "retained",
              "label": "Chart retained — pull for reference"
            },
            {
              "goto": "s11",
              "id": "archived-or-elsewhere",
              "label": "Archived or with a different practice — request records"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the prior chart still retained by this practice?"
        },
        {
          "detail": "Flag the chart for the treating provider to review as historical reference, not as current clinical status.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Pull the retained prior chart for clinical reference"
        },
        {
          "detail": "Write the gap length, reason for return if volunteered, prior-chart or records-request status, and comprehensive/re-establishment coding into the chart.\n\nRecord: Gap length, reason for return if volunteered, whether prior chart was pulled or records requested, and that the visit is coded as comprehensive/re-establishment.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Note the re-establishment status in the chart"
        },
        {
          "detail": "Give the hygienist and treating provider the updated health history, gap length, and any prior-records status before the appointment starts.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the clinical team for the comprehensive exam visit"
        },
        {
          "detail": "Patient re-established; comprehensive exam visit proceeds",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Patient re-established; comprehensive exam visit proceeds"
        },
        {
          "detail": "Rerouted to standard recall booking (gap under threshold)",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Rerouted to standard recall booking (gap under threshold)"
        },
        {
          "detail": "With the patient's signed authorization, send a written records request; note in the chart if records are not received before the visit.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Send a records-request to the prior practice, if named"
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Returning patient after three or more years (re-establish as new) — A patient returns after a gap long enough to require new records and a comprehensive exam.",
      "title": "Returning patient after three or more years (re-establish as new)",
      "trigger": "A patient returns after a gap long enough to require new records and a comprehensive exam",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — survey texts and emails",
          "source": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — survey texts and emails"
        },
        {
          "kind": "regulation",
          "label": "FTC Endorsement Guides 16 CFR Part 255 — no incentivized or gated reviews",
          "source": "FTC Endorsement Guides 16 CFR Part 255 — no incentivized or gated reviews",
          "url": "https://www.ecfr.gov/current/title-16/part-255"
        },
        {
          "kind": "generic",
          "label": "For a short post-visit satisfaction survey — no survey-vendor system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a short post-visit satisfaction survey — no survey-vendor system reproduced"
          },
          "source": "For a short post-visit satisfaction survey — no survey-vendor system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "rrr-005",
      "kind": "operational",
      "materials": [
        "survey template (text or email link)",
        "consent-to-contact flag list",
        "survey results tracking sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull the list of patients seen the prior business day who are flagged as consented to contact for surveys.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Build the daily send list from completed visits"
        },
        {
          "detail": "Send a short text or email with a link to a brief satisfaction questionnaire; the questionnaire asks about wait time, staff courtesy and overall experience, never for clinical detail.\n\nWhy: Keeping the survey to satisfaction questions, not clinical content, keeps the tool itself free of PHI regardless of how it is stored downstream.",
          "id": "s2",
          "kind": "step",
          "role": "marketing",
          "title": "Send the survey 24 hours after the visit",
          "why": "Keeping the survey to satisfaction questions, not clinical content, keeps the tool itself free of PHI regardless of how it is stored downstream."
        },
        {
          "detail": "What did the response score?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "positive",
              "label": "Positive score — log and optionally invite a public review"
            },
            {
              "goto": "s7",
              "id": "negative",
              "label": "Below-threshold score — route to complaint resolution"
            },
            {
              "goto": "s8",
              "id": "no-response",
              "label": "No response received"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "marketing",
          "title": "What did the response score?"
        },
        {
          "detail": "If the patient scores positively, a separate, non-conditional invitation to leave a public review may be sent; it is never presented as contingent on the survey score and no incentive is attached.\n\nWhy: Gating or incentivizing which patients get asked to review, based on their survey score, is the exact selective-solicitation practice the FTC Endorsement Guides prohibit.",
          "id": "s4",
          "kind": "step",
          "role": "marketing",
          "title": "Optionally invite a public review, ungated",
          "why": "Gating or incentivizing which patients get asked to review, based on their survey score, is the exact selective-solicitation practice the FTC Endorsement Guides prohibit."
        },
        {
          "detail": "Write the send date, response status, score if received, and routing outcome onto the survey tracking sheet.\n\nRecord: Send date, response status, score if received, and whether it was routed to complaint resolution or review invitation.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Log the survey outcome"
        },
        {
          "detail": "Survey cycle complete for this patient",
          "id": "s6",
          "kind": "step",
          "role": "marketing",
          "title": "Survey cycle complete for this patient"
        },
        {
          "detail": "Forward the low score and any free-text comment to the office manager to open a complaint-intake record (rrr-006).",
          "id": "s7",
          "kind": "step",
          "role": "marketing",
          "title": "Hand off a low score to the complaint-intake protocol"
        },
        {
          "detail": "Mark the survey as sent with no response; no further follow-up is required for a satisfaction survey.",
          "id": "s8",
          "kind": "step",
          "role": "marketing",
          "title": "Log the non-response"
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Post-visit satisfaction survey (opt-in, no PHI in the survey) — 24 hours after a completed visit for patients who consented to contact.",
      "title": "Post-visit satisfaction survey (opt-in, no PHI in the survey)",
      "trigger": "24 hours after a completed visit for patients who consented to contact",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — acknowledgment and follow-up texts/calls to the complaining patient",
          "source": "TCPA 47 U.S.C. §227 — acknowledgment and follow-up texts/calls to the complaining patient",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        },
        {
          "kind": "generic",
          "label": "For a logged, acknowledged, owner-reviewed complaint-resolution workflow — no complaint-management vendor system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for a logged, acknowledged, owner-reviewed complaint-resolution workflow — no complaint-management vendor system reproduced"
          },
          "source": "For a logged, acknowledged, owner-reviewed complaint-resolution workflow — no complaint-management vendor system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "rrr-006",
      "kind": "operational",
      "materials": [
        "complaint log form",
        "acknowledgment message template",
        "resolution tracking sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "front-desk",
        "practice-owner",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Record the date, channel, patient, and a verbatim summary of the complaint on the complaint log, regardless of how minor it seems.\n\nWhy: An unlogged verbal complaint is invisible to the trend metrics that catch a recurring problem.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the complaint the moment it arrives",
          "why": "An unlogged verbal complaint is invisible to the trend metrics that catch a recurring problem."
        },
        {
          "detail": "Contact the patient to confirm the complaint was received and that it is being looked into; do not attempt to resolve it in this first contact.\n\nWhy: A fast acknowledgment de-escalates on its own, separate from whatever the eventual resolution is.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Acknowledge the complaint within one business day",
          "why": "A fast acknowledgment de-escalates on its own, separate from whatever the eventual resolution is."
        },
        {
          "detail": "Pull the relevant appointment, billing, or communication record; talk to any staff involved; note findings on the log.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Investigate the facts of the complaint"
        },
        {
          "detail": "What category is the complaint?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "service",
              "label": "Service/administrative — office manager can resolve directly"
            },
            {
              "goto": "s5",
              "id": "billing",
              "label": "Billing dispute — office manager can resolve directly"
            },
            {
              "goto": "s9",
              "id": "clinical",
              "label": "Clinical concern — requires dentist review before any resolution offer"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "What category is the complaint?"
        },
        {
          "detail": "Does this complaint's severity require practice-owner sign-off before a resolution is proposed to the patient?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "standard",
              "label": "Standard severity — office manager proposes the resolution directly"
            },
            {
              "goto": "s10",
              "id": "elevated",
              "label": "Elevated severity (financial exposure, repeat complainant, potential board/legal exposure) — owner reviews the proposed resolution first"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does this complaint's severity require practice-owner sign-off before a resolution is proposed to the patient?"
        },
        {
          "detail": "Present the findings and the proposed resolution (correction, credit, re-treatment, or explanation) to the patient directly; for an elevated-severity complaint this resolution has already been reviewed by the practice owner.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Propose a resolution to the patient"
        },
        {
          "detail": "Write the final resolution offered, the patient's response, the closure date, and the complaint category onto the complaint log.\n\nRecord: Final resolution offered, patient's response, closure date, and category for trend tracking.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Close the complaint with the patient and log the outcome"
        },
        {
          "detail": "Complaint closed",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Complaint closed"
        },
        {
          "detail": "A clinical complaint (treatment outcome, pain, a re-do request) is reviewed by the treating or supervising dentist before any resolution, credit, or re-treatment is offered to the patient.\n\nWhy: Resolving a clinical complaint at the front-office level without a licensed provider's review risks a wrong clinical judgment being presented to the patient as the practice's answer.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed clinical review before any clinical complaint is resolved.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed clinical review before any clinical complaint is resolved",
          "why": "Resolving a clinical complaint at the front-office level without a licensed provider's review risks a wrong clinical judgment being presented to the patient as the practice's answer."
        },
        {
          "detail": "The practice owner reviews the facts and the proposed resolution before anything is communicated to the patient, so a promise the practice cannot support is never made in the first place.\n\nWhy: Money, repeat patterns and legal exposure decisions belong at the ownership level before a resolution is voiced to the patient, not after — walking back an already-offered resolution is its own service and legal problem.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Owner sign-off before an elevated-severity resolution is offered to the patient.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Owner sign-off before an elevated-severity resolution is offered to the patient",
          "why": "Money, repeat patterns and legal exposure decisions belong at the ownership level before a resolution is voiced to the patient, not after — walking back an already-offered resolution is its own service and legal problem."
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Patient complaint intake and resolution — A complaint arrives by any channel — logged, acknowledged within one business day, owner-reviewed, closed with the patient.",
      "title": "Patient complaint intake and resolution",
      "trigger": "A complaint arrives by any channel — logged, acknowledged within one business day, owner-reviewed, closed with the patient",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Anti-kickback 42 U.S.C. §1320a-7b (federal programs) and California B&P §650 — referral thank-yous",
          "source": "Anti-kickback 42 U.S.C. §1320a-7b (federal programs) and California B&P §650 — referral thank-yous",
          "url": "https://www.law.cornell.edu/uscode/text/42/1320a-7b"
        },
        {
          "kind": "generic",
          "label": "For capturing a referral source and sending a compliant thank-you — no marketing-consultancy system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for capturing a referral source and sending a compliant thank-you — no marketing-consultancy system reproduced"
          },
          "source": "For capturing a referral source and sending a compliant thank-you — no marketing-consultancy system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "rrr-007",
      "kind": "operational",
      "materials": [
        "referral-source capture field on the intake form",
        "approved thank-you note/gift policy (value ceiling defined)",
        "referral tracking log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "marketing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Ask every new patient how they heard about the practice and record a named referral source (patient or professional) on the intake form.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Capture the referral source on intake"
        },
        {
          "detail": "Is the referral source a patient or a referring professional?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "patient-source",
              "label": "Existing patient referred a friend/family member"
            },
            {
              "goto": "s8",
              "id": "professional-source",
              "label": "Referring professional (e.g. specialist, physician)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the referral source a patient or a referring professional?"
        },
        {
          "detail": "Check the planned note, call, or small non-cash token against the practice's defined value ceiling before it is sent.\n\nWhy: Anti-kickback statute and California B&P §650 prohibit anything that functions as payment for a referral; staying under a modest, non-cash, disclosed ceiling is how the practice keeps a thank-you from becoming a kickback.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the thank-you stays within the approved value ceiling",
          "why": "Anti-kickback statute and California B&P §650 prohibit anything that functions as payment for a referral; staying under a modest, non-cash, disclosed ceiling is how the practice keeps a thank-you from becoming a kickback."
        },
        {
          "detail": "Is the planned thank-you within the value ceiling and non-cash?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "within",
              "label": "Within ceiling and non-cash — send as planned"
            },
            {
              "goto": "s9",
              "id": "over",
              "label": "Over ceiling or cash-equivalent — reduce or reject before sending"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the planned thank-you within the value ceiling and non-cash?"
        },
        {
          "detail": "Send the approved note, call, or small non-cash token to the referral source, thanking them without conditioning any future treatment or benefit on further referrals.",
          "id": "s5",
          "kind": "step",
          "role": "marketing",
          "title": "Send the thank-you note or call"
        },
        {
          "detail": "Write the new patient's name, the referral source, the thank-you channel and value, and the date sent onto the referral tracking log.\n\nRecord: New patient name, referral source, thank-you channel and value, and date sent.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the referral and thank-you in the tracking log"
        },
        {
          "detail": "Referral thank-you complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Referral thank-you complete"
        },
        {
          "detail": "Because the source is a referring healthcare professional rather than a patient, apply the practice's lower professional-referral value ceiling and confirm the thank-you is not linked to referral volume, frequency, or any expectation of future referrals, since anti-kickback exposure is materially higher for referrals among healthcare providers than for patient-to-patient referrals.\n\nWhy: Anti-kickback scrutiny on payments or gifts to a referring healthcare professional is a distinct and higher-risk category than a patient thanking another patient, and treating them identically understates that risk.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Apply the stricter professional-referral standard before the value check",
          "why": "Anti-kickback scrutiny on payments or gifts to a referring healthcare professional is a distinct and higher-risk category than a patient thanking another patient, and treating them identically understates that risk."
        },
        {
          "detail": "Any planned thank-you that is cash, a cash-equivalent, or above the defined value ceiling is reviewed by the compliance officer before anything is sent to the referral source.\n\nWhy: A referral thank-you that functions as payment risks the practice, not just the individual staff member who sent it, under anti-kickback law.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance review before any thank-you exceeding the ceiling ships.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance review before any thank-you exceeding the ceiling ships",
          "why": "A referral thank-you that functions as payment risks the practice, not just the individual staff member who sent it, under anti-kickback law."
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Thanking a referring patient or professional (no kickbacks) — A new patient names a referral source.",
      "title": "Thanking a referring patient or professional (no kickbacks)",
      "trigger": "A new patient names a referral source",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — outreach compliance depends on maintaining valid, consented contact records",
          "source": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — outreach compliance depends on maintaining valid, consented contact records",
          "url": "https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title47-section227&num=0&edition=prelim",
          "url_verified_at": "2026-09-14"
        },
        {
          "kind": "generic",
          "label": "For monthly database hygiene (duplicates, deceased/moved/bad-contact flags) — no PMS-vendor system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for monthly database hygiene (duplicates, deceased/moved/bad-contact flags) — no PMS-vendor system reproduced"
          },
          "source": "For monthly database hygiene (duplicates, deceased/moved/bad-contact flags) — no PMS-vendor system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 60,
      "frequency": "monthly",
      "id": "rrr-008",
      "kind": "operational",
      "materials": [
        "practice management system duplicate-record report",
        "bounced-mail/bounced-text report",
        "returned-mail log",
        "database hygiene checklist"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull the practice management system's likely-duplicate report (matching on name, date of birth, and address/phone combinations).",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Run the monthly duplicate-record report"
        },
        {
          "detail": "For each flagged pair, confirm they are the same patient before merging; merge into the record with the fuller and more recent history, preserving both records' visit history.\n\nWhy: A wrongful merge can blend two different patients' clinical histories, which is worse than leaving a duplicate unresolved.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Review and merge confirmed duplicates",
          "why": "A wrongful merge can blend two different patients' clinical histories, which is worse than leaving a duplicate unresolved."
        },
        {
          "detail": "Pull the month's bounced/returned contact-attempt reports and cross-reference against active recall records.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Review bounced-text, bounced-email and returned-mail reports"
        },
        {
          "detail": "What is the reason for the bad contact info?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "moved",
              "label": "Patient moved / new contact info available"
            },
            {
              "goto": "s9",
              "id": "deceased",
              "label": "Patient reported deceased"
            },
            {
              "goto": "s10",
              "id": "unknown",
              "label": "Reason unknown — bad number/address with no update available"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "front-desk",
          "title": "What is the reason for the bad contact info?"
        },
        {
          "detail": "Update phone, email, or mailing address once a reliable new contact method is confirmed (from the patient, a family member, or a returned-mail forwarding notice).",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Update the record with the new contact info"
        },
        {
          "detail": "Write the number of duplicates merged, the number flagged deceased, moved, or invalid, and any IT escalation onto the monthly cleanup log.\n\nRecord: Number of duplicates merged, number flagged deceased/moved/invalid, and any records escalated to IT for a system-level data issue.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the month's cleanup pass"
        },
        {
          "detail": "Did this pass surface a recurring system-level data issue?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-issue",
              "label": "No system issue found"
            },
            {
              "goto": "s11",
              "id": "issue",
              "label": "Recurring issue found (e.g. repeated malformed imports)"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did this pass surface a recurring system-level data issue?"
        },
        {
          "detail": "Monthly database hygiene pass complete",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Monthly database hygiene pass complete"
        },
        {
          "detail": "Mark the record deceased in the practice management system and remove it from all recall, reactivation and survey outreach lists.\n\nWhy: Continuing to contact a deceased patient's household is both a data-quality failure and can cause real distress to family.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the record deceased and remove from active outreach",
          "why": "Continuing to contact a deceased patient's household is both a data-quality failure and can cause real distress to family."
        },
        {
          "detail": "Mark the contact method invalid and exclude the record from automated outreach until a valid method is obtained at the patient's next contact with the practice.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the record as invalid contact, pending update"
        },
        {
          "detail": "Hand off a description of the recurring pattern (e.g. a bad import source creating repeat duplicates) to the IT vendor for a root-cause fix.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Escalate the recurring data issue to IT"
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Patient database hygiene (duplicates, deceased, moved, bad numbers) — Monthly cleanup pass on the patient database.",
      "title": "Patient database hygiene (duplicates, deceased, moved, bad numbers)",
      "trigger": "Monthly cleanup pass on the patient database",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for outreach cadences and complaint handling scripts (recall-reactivation-and-retention class floor)",
          "source": "Generic functional equivalent for outreach cadences and complaint handling scripts (recall-reactivation-and-retention class floor)"
        },
        {
          "kind": "generic",
          "label": ": standard practice-management retention metrics (hygiene reappointment rate, active-patient count, attrition/lapse rate) — no consultancy scorecard reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent: standard practice-management retention metrics (hygiene reappointment rate, active-patient count, attrition/lapse rate) — no consultancy scorecard reproduced"
          },
          "source": ": standard practice-management retention metrics (hygiene reappointment rate, active-patient count, attrition/lapse rate) — no consultancy scorecard reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 45,
      "frequency": "monthly",
      "id": "rrr-009",
      "kind": "operational",
      "materials": [
        "practice management system reporting module",
        "prior-month metrics spreadsheet or dashboard",
        "numbers-meeting template"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Run the built-in or exported report covering hygiene reappointment percentage, total active patients, new patients, and patients who lapsed out of active status during the month.\n\nWhy: Using the same report source every month keeps the trend comparable and avoids hand-recounting.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Pull the standard retention report from the practice management system",
          "why": "Using the same report source every month keeps the trend comparable and avoids hand-recounting."
        },
        {
          "detail": "Divide patients who moved from active to inactive status during the month by the active patient count at the start of the month; record as a percentage.\n\nWhy: A consistent formula lets the number be compared month over month instead of re-derived each time.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Compute the attrition rate for the month",
          "why": "A consistent formula lets the number be compared month over month instead of re-derived each time."
        },
        {
          "detail": "Divide the number of hygiene patients who left their visit with a future hygiene appointment booked by the total hygiene patients seen that month.\n\nWhy: Reappointment percentage is the leading indicator that predicts next month's due-and-unscheduled list, ahead of the attrition number.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Compute the hygiene reappointment percentage",
          "why": "Reappointment percentage is the leading indicator that predicts next month's due-and-unscheduled list, ahead of the attrition number."
        },
        {
          "detail": "Is any metric below its practice-set target threshold?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "within-target",
              "label": "All metrics are at or above target"
            },
            {
              "goto": "s9",
              "id": "below-target",
              "label": "One or more metrics fell below target"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is any metric below its practice-set target threshold?"
        },
        {
          "detail": "Add the month's hygiene reappointment percentage, active patient count, attrition rate, and any driver notes as a new row, preserving prior months for trend view.\n\nRecord: hygiene reappointment %, active patient count, attrition rate, driver notes, month",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the month's metrics to the tracking spreadsheet or dashboard"
        },
        {
          "detail": "Chart or table the last six months of each metric alongside target thresholds so trend direction is visible at a glance.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Prepare a one-page summary for the numbers meeting"
        },
        {
          "detail": "Bring the one-page summary to the monthly numbers meeting for review with the practice owner and relevant team leads.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the summary to the numbers meeting"
        },
        {
          "detail": "Retention metrics logged and ready for the numbers meeting",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Retention metrics logged and ready for the numbers meeting"
        },
        {
          "detail": "Add a one-line note next to the metric — e.g. a hygienist out on leave, a holiday-shortened month, a batch of unscheduled recall — so the numbers meeting has context rather than a bare number.\n\nWhy: A number without context invites guessing at the meeting; a noted likely driver keeps the discussion focused.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Note a likely driver for each metric that missed target",
          "why": "A number without context invites guessing at the meeting; a noted likely driver keeps the discussion focused."
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Retention metrics (hygiene reappointment %, active patients, attrition) — Monthly, feeding the numbers meeting.",
      "title": "Retention metrics (hygiene reappointment %, active patients, attrition)",
      "trigger": "Monthly, feeding the numbers meeting",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "source": "TCPA 47 U.S.C. §227 and CAN-SPAM 15 U.S.C. §7701 — recall texts, calls and emails",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        },
        {
          "kind": "regulation",
          "label": "FTC Endorsement Guides 16 CFR Part 255 — no incentivized or gated reviews",
          "source": "FTC Endorsement Guides 16 CFR Part 255 — no incentivized or gated reviews",
          "url": "https://www.ecfr.gov/current/title-16/part-255"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for outreach cadences and complaint handling scripts (recall-reactivation-and-retention class floor)",
          "source": "Generic functional equivalent for outreach cadences and complaint handling scripts (recall-reactivation-and-retention class floor)"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 90,
      "frequency": "annual",
      "id": "rrr-010",
      "kind": "operational",
      "materials": [
        "practice management system treatment-plan report",
        "insurance benefit-remaining report",
        "outreach script or template (call, text, letter)",
        "scheduling calendar with year-end capacity held"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "insurance-coordinator",
        "front-desk",
        "marketing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Run a report cross-referencing patients with an unmet insurance annual maximum, or a self-reported FSA/HSA balance, against the practice's pending or unscheduled treatment plans.\n\nWhy: October gives roughly two to three months of scheduling runway before calendar-year benefits reset or FSA funds lapse.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Pull the list of patients with remaining annual maximum or FSA balance and pending treatment",
          "why": "October gives roughly two to three months of scheduling runway before calendar-year benefits reset or FSA funds lapse."
        },
        {
          "detail": "Sort the list so patients with the largest unused benefit and the most clinically time-sensitive pending treatment are contacted first.\n\nWhy: Limited pre-year-end appointment capacity means the highest-value and most time-sensitive cases should be reached before the list is worked in order.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Prioritize the list by dollar value and treatment urgency",
          "why": "Limited pre-year-end appointment capacity means the highest-value and most time-sensitive cases should be reached before the list is worked in order."
        },
        {
          "detail": "Reserve a set number of treatment slots in November and December before the general schedule fills, so patients who respond have somewhere to go.\n\nWhy: Outreach without available appointment slots produces frustrated patients and a wasted campaign.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Hold a block of year-end appointment capacity for this campaign",
          "why": "Outreach without available appointment slots produces frustrated patients and a wasted campaign."
        },
        {
          "detail": "Send a brief message noting the patient has remaining benefits or FSA funds that may expire, and pending recommended treatment, with a link or number to schedule.\n\nWhy: TCPA and CAN-SPAM require the outreach channel and content to match what the patient consented to receive.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the first-touch outreach (text or email)",
          "why": "TCPA and CAN-SPAM require the outreach channel and content to match what the patient consented to receive."
        },
        {
          "detail": "Did the patient respond or schedule within one week?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "scheduled",
              "label": "Patient scheduled or confirmed a plan"
            },
            {
              "goto": "s9",
              "id": "no-response",
              "label": "No response after one week"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the patient respond or schedule within one week?"
        },
        {
          "detail": "Log whether the patient scheduled, declined, or could not be reached, and note the dollar value of benefit converted to scheduled treatment.\n\nRecord: contact channel used, response, scheduled or declined status, benefit dollar value converted",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Record the outcome for each patient on the list"
        },
        {
          "detail": "Total the number contacted, number scheduled, and dollar value of benefits converted to completed or scheduled treatment for review at the next numbers meeting.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Compile a campaign summary once the list is fully worked"
        },
        {
          "detail": "Year-end benefits outreach campaign complete",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Year-end benefits outreach campaign complete"
        },
        {
          "detail": "Call the patient, reference the earlier message, restate the remaining benefit or FSA amount and the pending treatment, and offer specific available appointment times.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Follow up with a phone call"
        },
        {
          "detail": "What was the outcome of the call?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "call-scheduled",
              "label": "Patient scheduled"
            },
            {
              "goto": "s6",
              "id": "call-declined",
              "label": "Patient declined or asked not to be contacted further this cycle"
            },
            {
              "goto": "s11",
              "id": "call-no-answer",
              "label": "No answer — leave voicemail and send a final letter"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "front-desk",
          "title": "What was the outcome of the call?"
        },
        {
          "detail": "Mail a short letter restating the deadline and remaining benefit, since mail sometimes reaches patients who do not respond to text, email or phone.",
          "id": "s11",
          "kind": "step",
          "role": "marketing",
          "title": "Send a final mailed letter as the last-touch reminder"
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Year-end unused-benefits and FSA-deadline outreach — October arrives — patients with remaining annual maximum or FSA balances and pending treatment are identified and contacted.",
      "title": "Year-end unused-benefits and FSA-deadline outreach",
      "trigger": "October arrives — patients with remaining annual maximum or FSA balances and pending treatment are identified and contacted",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA 45 CFR 164.502(f) — protections for a deceased individual's health information continue after death; disclosures to family/estate follow the Privacy Rule's personal-representative and next-of-kin provisions (45 CFR 164.502(g))",
          "source": "HIPAA 45 CFR 164.502(f) — protections for a deceased individual's health information continue after death; disclosures to family/estate follow the Privacy Rule's personal-representative and next-of-kin provisions (45 CFR 164.502(g))",
          "url": "https://www.ecfr.gov/current/title-45/section-164.502"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for outreach cadences and complaint handling scripts (recall-reactivation-and-retention class floor)",
          "source": "Generic functional equivalent for outreach cadences and complaint handling scripts (recall-reactivation-and-retention class floor)"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rrr-011",
      "kind": "operational",
      "materials": [
        "practice management system",
        "chart flag / deceased status field",
        "outstanding balance report",
        "records-request log",
        "condolence card or note (optional)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note how the report arrived — a family phone call, a found obituary, or returned mail marked deceased — and who reported it, without making any assumptions from a single unverified source.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Receive the report that a patient has died"
        },
        {
          "detail": "Remove or suspend the patient from all recall lists, appointment reminders, statement runs, satisfaction surveys and marketing campaigns right away, before verification is complete.\n\nWhy: A recall text or bill reaching a grieving family causes real harm and is easy to prevent by pausing first and verifying second.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Immediately pause all recall, reactivation, billing-reminder and marketing outreach to the patient",
          "why": "A recall text or bill reaching a grieving family causes real harm and is easy to prevent by pausing first and verifying second."
        },
        {
          "detail": "Is the report from a source the office can reasonably verify (obituary, family member with identifying details, or returned mail)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "verifiable",
              "label": "Source is reasonably verifiable (published obituary, family caller who can confirm identifying details, or official returned mail)"
            },
            {
              "goto": "s12",
              "id": "unverifiable",
              "label": "Source is a rumor or an anonymous tip with no confirming detail"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the report from a source the office can reasonably verify (obituary, family member with identifying details, or returned mail)?"
        },
        {
          "detail": "Have the office manager review the reported source and approve flagging the chart as deceased in the practice management system; this is the consequential, hard-to-reverse step so it is not left to whoever answered the phone.\n\nWhy: Flagging a chart deceased changes how the practice treats every future contact and any records request, so it gets a named sign-off rather than an unreviewed field edit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager sign-off before the chart is formally flagged deceased.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager sign-off before the chart is formally flagged deceased",
          "why": "Flagging a chart deceased changes how the practice treats every future contact and any records request, so it gets a named sign-off rather than an unreviewed field edit."
        },
        {
          "detail": "Set the deceased status field, record the date reported and the source, and confirm the patient no longer appears on any active or recall list.\n\nRecord: deceased status, date reported, source of report, name of staff who confirmed",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the chart as deceased in the practice management system"
        },
        {
          "detail": "Pull the patient's outstanding balance, if any, and determine the practice's standard path — routing to the estate's representative, holding pending an estate contact, or writing off per practice policy.\n\nWhy: A death in the family is not the moment for a routine collections call; the account still needs a documented resolution path, just not an automated one.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Review any outstanding account balance",
          "why": "A death in the family is not the moment for a routine collections call; the account still needs a documented resolution path, just not an automated one."
        },
        {
          "detail": "Is there an outstanding balance on the account?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no-balance",
              "label": "No outstanding balance"
            },
            {
              "goto": "s14",
              "id": "balance-exists",
              "label": "There is an outstanding balance"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "billing",
          "title": "Is there an outstanding balance on the account?"
        },
        {
          "detail": "If the practice's policy is to send condolences, prepare a brief, sincere note; this is optional and practice-specific, not a required compliance step.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Decide whether to send a condolence note to the family"
        },
        {
          "detail": "Has the family or an estate representative requested the patient's records?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "no-request",
              "label": "No records request has been made"
            },
            {
              "goto": "s15",
              "id": "records-requested",
              "label": "Family or estate representative is requesting records"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Has the family or an estate representative requested the patient's records?"
        },
        {
          "detail": "Once outreach is paused, the chart is flagged, the balance is routed, and any records request is resolved, move the chart to the archived status used for retention purposes.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Move the chart to archived/inactive status per the practice's retention schedule"
        },
        {
          "detail": "Deceased-patient handling complete: outreach stopped, chart flagged, balance routed, records request resolved",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Deceased-patient handling complete: outreach stopped, chart flagged, balance routed, records request resolved"
        },
        {
          "detail": "Keep outreach paused, but do not mark the chart deceased yet; attempt a low-key confirmation such as checking a public obituary index before proceeding further.\n\nWhy: Marking a living patient deceased in error is its own harm; pausing outreach is reversible and low-risk while confirmation is pending.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Hold the chart in paused-outreach status pending confirmation",
          "why": "Marking a living patient deceased in error is its own harm; pausing outreach is reversible and low-risk while confirmation is pending."
        },
        {
          "detail": "Has the hold exceeded the practice's stated confirmation window (e.g. 14 days) with still no confirming evidence?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "within-window",
              "label": "Still within the confirmation window — keep attempting to confirm"
            },
            {
              "goto": "s17",
              "id": "window-exceeded",
              "label": "Confirmation window exceeded with no confirming evidence"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "office-manager",
          "title": "Has the hold exceeded the practice's stated confirmation window (e.g. 14 days) with still no confirming evidence?"
        },
        {
          "detail": "Route the balance per the practice's standard policy for estate accounts — typically a written notice to the estate representative once identified, held rather than sent to routine collections.",
          "id": "s14",
          "kind": "step",
          "role": "billing",
          "title": "Hand the balance to the practice's estate-billing process"
        },
        {
          "detail": "Verify the requester's standing as a personal representative of the estate (or other authority recognized under the practice's records policy) before releasing any portion of the deceased patient's chart.\n\nWhy: HIPAA's protections continue after death (45 CFR 164.502(f)); releasing records to whoever calls and claims to be family, without verifying standing, is a privacy breach even though the patient has died.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance verification before any records are released.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s15",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance verification before any records are released",
          "why": "HIPAA's protections continue after death (45 CFR 164.502(f)); releasing records to whoever calls and claims to be family, without verifying standing, is a privacy breach even though the patient has died."
        },
        {
          "detail": "Log who requested the records, what standing was verified, what was released, and the date, in the records-request log.\n\nRecord: requester identity and verified standing, records released, date",
          "id": "s16",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the records release"
        },
        {
          "detail": "Restore the patient to normal recall, reactivation, billing-reminder and marketing outreach, since an unconfirmed report cannot indefinitely suspend contact with a patient who may be alive; log the report and the reason it could not be confirmed.\n\nWhy: A rumor that never resolves must not be allowed to silently and permanently drop a living patient from every outreach list.",
          "id": "s17",
          "kind": "step",
          "role": "office-manager",
          "title": "Resume normal outreach and log the report as unconfirmed",
          "why": "A rumor that never resolves must not be allowed to silently and permanently drop a living patient from every outreach list."
        },
        {
          "detail": "Unconfirmed death report resolved: outreach resumed, report logged as unconfirmed",
          "id": "s18",
          "kind": "step",
          "role": "office-manager",
          "title": "Unconfirmed death report resolved: outreach resumed, report logged as unconfirmed"
        }
      ],
      "subclass": "recall-reactivation-and-retention",
      "summary": "Patient death learned (obituary, family call): stop outreach, flag chart, records and balance to estate — A family member calls, an obituary is found, or mail returns marked deceased for an active patient.",
      "title": "Patient death learned (obituary, family call): stop outreach, flag chart, records and balance to estate",
      "trigger": "A family member calls, an obituary is found, or mail returns marked deceased for an active patient",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        },
        {
          "kind": "open_standard",
          "label": "ADA evidence-based guideline on acute dental pain management (2023) — members-gated, no stable public URL",
          "source": "ADA evidence-based guideline on acute dental pain management (2023) — members-gated, no stable public URL"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "rx-001",
      "kind": "clinical",
      "materials": [
        "chart / practice management system",
        "post-op instruction sheet",
        "NSAID and acetaminophen dosing reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Based on the procedure type and patient factors, estimate mild/moderate/severe expected post-op pain.\n\nWhy: The evidence-based ladder starts from procedure-specific expected pain, not a default prescription habit.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Assess expected post-operative pain level for the procedure performed",
          "why": "The evidence-based ladder starts from procedure-specific expected pain, not a default prescription habit."
        },
        {
          "detail": "Review chart for renal disease, GI bleed history, anticoagulant use, liver disease, NSAID allergy, or acetaminophen dose limits from other medications.\n\nRecord: Contraindication review noted in chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Check NSAID/acetaminophen contraindications"
        },
        {
          "detail": "Select first-line analgesic plan",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "combo",
              "label": "Scheduled ibuprofen + acetaminophen (no contraindications)"
            },
            {
              "goto": "s4",
              "id": "single-agent",
              "label": "Single agent only (contraindication to one class)"
            },
            {
              "goto": "s8",
              "id": "escalate",
              "label": "Expected severe pain or NSAID/APAP alone judged insufficient"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Select first-line analgesic plan"
        },
        {
          "detail": "Dentist personally confirms the selected analgesic plan matches the exam findings and contraindication review before it is written up for the patient.\n\nWhy: Any post-operative medication plan is a clinical/prescribing decision and must carry the prescriber's own sign-off, not just staff execution.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the analgesic plan before it goes to the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the analgesic plan before it goes to the patient",
          "why": "Any post-operative medication plan is a clinical/prescribing decision and must carry the prescriber's own sign-off, not just staff execution."
        },
        {
          "detail": "Write the agents, doses, schedule, and duration into the chart and print or send the instruction sheet to the patient.\n\nRecord: Analgesic plan (agents, doses, schedule, duration) recorded in chart and printed/sent to patient",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the analgesic plan and give written instructions"
        },
        {
          "detail": "Explain that scheduled alternating or combined NSAID/acetaminophen dosing controls pain as well as or better than opioids for most dental procedures, with fewer side effects.\n\nWhy: Patient expectation-setting reduces after-hours calls requesting an opioid.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Counsel patient on the scheduled (not as-needed-only) dosing rationale",
          "why": "Patient expectation-setting reduces after-hours calls requesting an opioid."
        },
        {
          "detail": "Analgesic plan in place",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Analgesic plan in place"
        },
        {
          "detail": "Do not default to an opioid here — hand off to the opioid-prescribing-exception-and-pdmp-check protocol (rx-002), which requires its own PDMP check and documented exception criteria before any opioid is written.\n\nWhy: Keeping the exception path in its own gated protocol prevents opioid prescribing from becoming the path of least resistance.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the opioid-exception protocol",
          "why": "Keeping the exception path in its own gated protocol prevents opioid prescribing from becoming the path of least resistance."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Post-procedure analgesia — NSAID and acetaminophen first, opioid only by exception — Any procedure expected to cause post-operative pain.",
      "title": "Post-procedure analgesia — NSAID and acetaminophen first, opioid only by exception",
      "trigger": "Any procedure expected to cause post-operative pain",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        },
        {
          "kind": "statute",
          "label": "California CURES mandatory consultation, H&S §11165.4",
          "source": "California CURES mandatory consultation, H&S §11165.4",
          "url": "https://oag.ca.gov/cures"
        },
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Part 1306 (prescription requirements)",
          "source": "DEA regulations 21 CFR Part 1306 (prescription requirements)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rx-002",
      "kind": "clinical",
      "materials": [
        "CURES/PDMP portal access",
        "chart / practice management system",
        "e-prescribing system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Does the case meet documented exception criteria for an opioid?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "yes",
              "label": "Yes — major surgical procedure, NSAID/APAP judged insufficient, documented"
            },
            {
              "goto": "s10",
              "id": "no",
              "label": "No — return to the NSAID/acetaminophen-first protocol"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the case meet documented exception criteria for an opioid?"
        },
        {
          "detail": "Query the state prescription drug monitoring program for this patient before writing the prescription; document the query date and findings in the chart.\n\nWhy: California law requires PDMP consultation before initially prescribing a Schedule II–IV controlled substance; it also surfaces existing controlled-substance activity that changes the clinical decision.\n\nRecord: PDMP query date and findings recorded in chart",
          "gate": {
            "ack": "I confirm I have completed this step as written: Mandatory PDMP (CURES) consultation before any opioid is written.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Mandatory PDMP (CURES) consultation before any opioid is written",
          "why": "California law requires PDMP consultation before initially prescribing a Schedule II–IV controlled substance; it also surfaces existing controlled-substance activity that changes the clinical decision."
        },
        {
          "detail": "Does the PDMP result raise a concern (concurrent opioids, high MME, benzodiazepine overlap)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clear",
              "label": "No concerning findings"
            },
            {
              "goto": "s11",
              "id": "concern",
              "label": "Concerning findings present"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the PDMP result raise a concern (concurrent opioids, high MME, benzodiazepine overlap)?"
        },
        {
          "detail": "Per CDC guidance, prescribe the lowest effective dose of immediate-release opioid for no more than the number of days the expected pain will last — three days or less will often be sufficient, and more than seven days will rarely be needed.\n\nWhy: Duration and quantity, not just drug choice, drive diversion and dependence risk.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Select the lowest effective dose and shortest duration",
          "why": "Duration and quantity, not just drug choice, drive diversion and dependence risk."
        },
        {
          "detail": "Check the dose threshold, concurrent benzodiazepine use, or overdose-history criteria that trigger a statutory naloxone offer.\n\nWhy: Naloxone offer is a separate statutory obligation triggered by specific risk criteria, so the branch is enforced here rather than left as a prose instruction.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "meets",
              "label": "Criteria met — route to the naloxone-offer protocol before finalizing"
            },
            {
              "goto": "s7",
              "id": "not-met",
              "label": "Criteria not met"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does this prescription meet naloxone co-offer criteria?",
          "why": "Naloxone offer is a separate statutory obligation triggered by specific risk criteria, so the branch is enforced here rather than left as a prose instruction."
        },
        {
          "detail": "Route to the naloxone-offer-with-opioid-prescription protocol (rx-003) — offer, patient decision, education or documented decline — as a required step before returning to finalize this prescription.\n\nWhy: The statutory naloxone-offer obligation must be completed before the prescription is finalized, not skipped as an unenforced note.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Complete the naloxone offer under rx-003 before finalizing",
          "why": "The statutory naloxone-offer obligation must be completed before the prescription is finalized, not skipped as an unenforced note."
        },
        {
          "detail": "Explain overdose risk, safe storage away from others, and disposal of unused pills (take-back program or DEA-approved disposal); e-prescribe per rx-007.\n\nWhy: Counseling reduces both misuse risk and unsecured leftover pills in the household.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Counsel patient on risks, storage, and disposal; send the prescription",
          "why": "Counseling reduces both misuse risk and unsecured leftover pills in the household."
        },
        {
          "detail": "Confirm the patient (or caregiver) has the printed instructions covering dosing, storage, disposal, and when to call the office.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Assistant confirms patient received written discharge instructions"
        },
        {
          "detail": "Opioid prescription completed with PDMP check documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Opioid prescription completed with PDMP check documented"
        },
        {
          "detail": "Opioid not indicated — non-opioid plan used instead",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Opioid not indicated — non-opioid plan used instead"
        },
        {
          "detail": "Discuss findings with the patient, consider non-opioid alternatives, and document the clinical reasoning for whatever plan is chosen.\n\nWhy: A concerning PDMP result changes the risk/benefit calculation and must be reasoned through, not overridden silently.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Reassess the pain-management plan in light of PDMP findings",
          "why": "A concerning PDMP result changes the risk/benefit calculation and must be reasoned through, not overridden silently."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Opioid prescription — exception criteria, PDMP check, lowest dose and shortest duration, counseling — The dentist judges an opioid necessary after a surgical procedure — the PDMP is checked first.",
      "title": "Opioid prescription — exception criteria, PDMP check, lowest dose and shortest duration, counseling",
      "trigger": "The dentist judges an opioid necessary after a surgical procedure — the PDMP is checked first",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California naloxone offer requirement, B&P §740",
          "source": "California naloxone offer requirement, B&P §740",
          "url": "https://oag.ca.gov/cures"
        },
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "rx-003",
      "kind": "clinical",
      "materials": [
        "naloxone offer/decline form",
        "patient education handout"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Does the prescription meet naloxone-offer risk criteria?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "meets",
              "label": "Meets criteria — dose threshold, concurrent benzodiazepine, or overdose history"
            },
            {
              "goto": "s7",
              "id": "no",
              "label": "Does not meet criteria"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the prescription meet naloxone-offer risk criteria?"
        },
        {
          "detail": "Explain that naloxone reverses opioid overdose and is a safety measure, not a judgment about the patient; offer a co-prescription or information on obtaining it over the counter.\n\nWhy: Framing matters — patients decline more often when the offer reads as an accusation rather than a safety default.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Offer naloxone and explain its purpose",
          "why": "Framing matters — patients decline more often when the offer reads as an accusation rather than a safety default."
        },
        {
          "detail": "Patient accepts or declines the naloxone offer",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "accept",
              "label": "Accept — co-prescribe or provide access information"
            },
            {
              "goto": "s8",
              "id": "decline",
              "label": "Decline"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "patient",
          "title": "Patient accepts or declines the naloxone offer"
        },
        {
          "detail": "Walk through recognizing overdose signs and administering naloxone (nasal spray or injectable, per product on hand); provide written instructions.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Educate patient/caregiver on naloxone administration"
        },
        {
          "detail": "Chart that the naloxone offer was made, accepted, and education was provided.\n\nRecord: Naloxone offer made and accepted, education provided, recorded in chart",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the offer and acceptance"
        },
        {
          "detail": "Naloxone offer completed and documented",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Naloxone offer completed and documented"
        },
        {
          "detail": "No statutory naloxone offer required for this prescription",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "No statutory naloxone offer required for this prescription"
        },
        {
          "detail": "Dentist confirms the patient understood the offer and its purpose before the decline is accepted and documented as final.\n\nWhy: A declined safety offer must be an informed decision, not a decline recorded from a rushed or unclear explanation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the decline is an informed decision before charting it.",
            "type": "safety"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm the decline is an informed decision before charting it",
          "why": "A declined safety offer must be an informed decision, not a decline recorded from a rushed or unclear explanation."
        },
        {
          "detail": "Chart that the naloxone offer was made, explained, and declined by the patient.\n\nRecord: Naloxone offer made and declined, recorded in chart",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document the decline"
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Naloxone offer and education when an opioid is prescribed (CA addendum) — An opioid prescription meets the statutory risk criteria (dose threshold, concurrent benzodiazepine, overdose history).",
      "title": "Naloxone offer and education when an opioid is prescribed (CA addendum)",
      "trigger": "An opioid prescription meets the statutory risk criteria (dose threshold, concurrent benzodiazepine, overdose history)",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA antibiotic guideline for dental pain and swelling (open) — members-gated, no stable public URL",
          "source": "ADA antibiotic guideline for dental pain and swelling (open) — members-gated, no stable public URL"
        },
        {
          "kind": "public_domain",
          "label": "CDC antibiotic stewardship resources",
          "source": "CDC antibiotic stewardship resources",
          "url": "https://www.cdc.gov/antibiotic-use/"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "rx-004",
      "kind": "clinical",
      "materials": [
        "chart / practice management system",
        "radiograph if indicated",
        "vital-sign equipment"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Exam and radiograph as needed to identify the source (caries, pulpitis, abscess, periodontal).\n\nWhy: Antibiotics do not fix a dental source; the definitive treatment is drainage, pulpal therapy, or extraction.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify and assess the dental source of pain or swelling",
          "why": "Antibiotics do not fix a dental source; the definitive treatment is drainage, pulpal therapy, or extraction."
        },
        {
          "detail": "Fever, malaise, facial swelling extending beyond the alveolar area, difficulty swallowing/breathing, trismus, lymphadenopathy.\n\nRecord: Systemic signs assessment recorded in chart",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Check for signs of systemic involvement"
        },
        {
          "detail": "Are systemic signs present or is source treatment unavailable today?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "localized",
              "label": "Localized findings only, source treatment can be done now"
            },
            {
              "goto": "s7",
              "id": "systemic",
              "label": "Systemic signs present, or source treatment must be delayed"
            },
            {
              "goto": "s9",
              "id": "severe",
              "label": "Airway compromise, spreading facial swelling, or difficulty breathing/swallowing"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Are systemic signs present or is source treatment unavailable today?"
        },
        {
          "detail": "Perform pulpal therapy, incision and drainage, or extraction as indicated; manage pain per the analgesic-ladder protocol (rx-001).\n\nWhy: Source control resolves localized infection without an antibiotic; unnecessary antibiotics drive resistance without benefit.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Treat the dental source; no antibiotic needed",
          "why": "Source control resolves localized infection without an antibiotic; unnecessary antibiotics drive resistance without benefit."
        },
        {
          "detail": "Explain that the definitive treatment is the procedure performed today, and that an antibiotic without source treatment would not resolve the infection.\n\nWhy: Patients who expect antibiotics need the clinical reasoning explained to avoid repeat requests or dissatisfaction.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Explain to the patient why an antibiotic is not being prescribed",
          "why": "Patients who expect antibiotics need the clinical reasoning explained to avoid repeat requests or dissatisfaction."
        },
        {
          "detail": "Antibiotic-stewardship decision made and documented",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Antibiotic-stewardship decision made and documented"
        },
        {
          "detail": "Dentist confirms systemic signs justify an antibiotic adjunct and that source treatment is scheduled, before the prescription is written.\n\nWhy: Prescribing an antibiotic without source treatment scheduled is the failure mode stewardship guidelines exist to prevent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off before an antibiotic is prescribed as an adjunct.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off before an antibiotic is prescribed as an adjunct",
          "why": "Prescribing an antibiotic without source treatment scheduled is the failure mode stewardship guidelines exist to prevent."
        },
        {
          "detail": "Perform source treatment today if feasible; if it must be delayed, prescribe an antibiotic as a bridge and schedule source treatment promptly. Check allergy status first (route to rx-005 if penicillin-allergic) and check interactions (rx-006).\n\nWhy: Systemic signs mean the infection may be spreading beyond what source treatment alone controls quickly enough.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Treat the source when possible and prescribe an antibiotic as an adjunct",
          "why": "Systemic signs mean the infection may be spreading beyond what source treatment alone controls quickly enough."
        },
        {
          "detail": "Airway-threatening spreading infection requires immediate emergency department or 911 referral, not an office antibiotic prescription alone.\n\nWhy: Deep space infection with airway involvement is a medical emergency outside the scope of outpatient antibiotic stewardship.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Refer for emergency care — this is not an office-managed antibiotic decision.",
            "type": "safety"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Refer for emergency care — this is not an office-managed antibiotic decision",
          "why": "Deep space infection with airway involvement is a medical emergency outside the scope of outpatient antibiotic stewardship."
        },
        {
          "detail": "Chart the time of referral, the reason (airway compromise, spreading facial swelling, or difficulty breathing/swallowing), whether EMS or the ED was contacted, and the patient's status at handoff.\n\nRecord: Time of referral, reason, EMS/ED contact confirmation, and patient status at handoff recorded in chart.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the emergency referral"
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Antibiotic stewardship — when to treat the source instead of prescribing — A patient asks for antibiotics or presents with pain or swelling.",
      "title": "Antibiotic stewardship — when to treat the source instead of prescribing",
      "trigger": "A patient asks for antibiotics or presents with pain or swelling",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA antibiotic guideline for dental pain and swelling (open) — members-gated, no stable public URL",
          "source": "ADA antibiotic guideline for dental pain and swelling (open) — members-gated, no stable public URL"
        },
        {
          "kind": "public_domain",
          "label": "CDC antibiotic stewardship resources",
          "source": "CDC antibiotic stewardship resources",
          "url": "https://www.cdc.gov/antibiotic-use/"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "rx-005",
      "kind": "clinical",
      "materials": [
        "chart / practice management system allergy field",
        "antibiotic alternatives reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Verify the allergy field in the chart matches what the patient reports today; update if changed.\n\nWhy: Allergy lists drift out of date; confirming at the visit prevents prescribing to a stale or incorrect record.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the penicillin allergy is documented and current",
          "why": "Allergy lists drift out of date; confirming at the visit prevents prescribing to a stale or incorrect record."
        },
        {
          "detail": "Ask what happened (rash, hives, swelling, difficulty breathing, GI upset only) and how long ago.\n\nWhy: True IgE-mediated allergy (hives, swelling, anaphylaxis) differs clinically from intolerance (GI upset) or a childhood reaction that may no longer apply — this changes which alternative is appropriate.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Ask the patient to describe the reaction",
          "why": "True IgE-mediated allergy (hives, swelling, anaphylaxis) differs clinically from intolerance (GI upset) or a childhood reaction that may no longer apply — this changes which alternative is appropriate."
        },
        {
          "detail": "Classify the reaction",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "severe",
              "label": "Anaphylaxis, hives, or angioedema reported"
            },
            {
              "goto": "s8",
              "id": "mild-or-unclear",
              "label": "Mild GI intolerance, or patient unsure of reaction type"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Classify the reaction"
        },
        {
          "detail": "Choose an alternative that avoids cross-reactivity risk with penicillins (e.g., clindamycin or a macrolide per current guideline), checking interactions per rx-006.\n\nWhy: True IgE-mediated allergy carries meaningful cross-reactivity risk with related beta-lactams.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Select a non-beta-lactam alternative",
          "why": "True IgE-mediated allergy carries meaningful cross-reactivity risk with related beta-lactams."
        },
        {
          "detail": "Dentist confirms the selected alternative is appropriate for the classified reaction type before the prescription is finalized.\n\nWhy: Cross-reactivity misjudgment can trigger a reaction, so the alternative selection carries its own sign-off rather than automatically following the classification.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the alternative agent before it is written.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the alternative agent before it is written",
          "why": "Cross-reactivity misjudgment can trigger a reaction, so the alternative selection carries its own sign-off rather than automatically following the classification."
        },
        {
          "detail": "Chart the reaction description, its classification, and the selected alternative antibiotic agent.\n\nRecord: Allergy reaction description, classification, and selected alternative agent recorded in chart",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document reaction classification and chosen alternative"
        },
        {
          "detail": "Alternative antibiotic selected and documented",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Alternative antibiotic selected and documented"
        },
        {
          "detail": "For non-severe or unclear history, select an alternative per current dental antibiotic guideline; consider referral for allergy testing if clarity would change future care materially.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Select an alternative or consider a cautious trial per current guideline"
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Penicillin allergy clarification and alternative selection — A patient lists a penicillin allergy and an antibiotic is indicated.",
      "title": "Penicillin allergy clarification and alternative selection",
      "trigger": "A patient lists a penicillin allergy and an antibiotic is indicated",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA MedWatch voluntary adverse-event reporting (Form 3500)",
          "source": "FDA MedWatch voluntary adverse-event reporting (Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        },
        {
          "kind": "public_domain",
          "label": "FDA-required prescribing information (labeling) Drug Interactions section (21 CFR 201.57), as published in the NLM DailyMed public drug label repository",
          "source": "FDA-required prescribing information (labeling) Drug Interactions section (21 CFR 201.57), as published in the NLM DailyMed public drug label repository",
          "url": "https://dailymed.nlm.nih.gov/dailymed/"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "rx-006",
      "kind": "clinical",
      "materials": [
        "chart / practice management system medication list",
        "e-prescribing interaction checker",
        "drug interaction reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask the patient to confirm current prescription, OTC, and supplement use; update the chart's medication list.\n\nWhy: An interaction screen is only as good as the medication list it runs against.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the patient's current medication list is up to date",
          "why": "An interaction screen is only as good as the medication list it runs against."
        },
        {
          "detail": "Use the e-prescribing system's built-in interaction checker (or a reference source if e-prescribing is unavailable) against the updated medication list.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Run the interaction check for the intended prescription"
        },
        {
          "detail": "Does the screen flag an interaction?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clear",
              "label": "No significant interaction flagged"
            },
            {
              "goto": "s6",
              "id": "flag",
              "label": "Interaction flagged"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the screen flag an interaction?"
        },
        {
          "detail": "Chart the interaction check result, any mitigation taken, and finalize the prescription for sending.\n\nRecord: Interaction check result and any resulting decision recorded in chart",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Document the interaction check outcome and finalize the prescription"
        },
        {
          "detail": "Interaction screen completed and documented",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Interaction screen completed and documented"
        },
        {
          "detail": "Assess the severity of the flagged interaction",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "minor",
              "label": "Minor/manageable — proceed with monitoring or dose adjustment"
            },
            {
              "goto": "s8",
              "id": "major",
              "label": "Major/contraindicated — select an alternative agent"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Assess the severity of the flagged interaction"
        },
        {
          "detail": "Dentist confirms the interaction screen result and, where flagged, the mitigation or alternative chosen, before finalizing the prescription.\n\nWhy: A flagged interaction is a prescribing-safety decision and needs an explicit sign-off step, not an implicit pass-through.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the final agent before it is prescribed.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the final agent before it is prescribed",
          "why": "A flagged interaction is a prescribing-safety decision and needs an explicit sign-off step, not an implicit pass-through."
        },
        {
          "detail": "Choose a different drug in the same class or a different approach, then re-run the interaction check before proceeding.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Select an alternative agent and re-screen"
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Drug interaction screen before any prescription — A prescription is about to be written for a patient on other medications.",
      "title": "Drug interaction screen before any prescription",
      "trigger": "A prescription is about to be written for a patient on other medications",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California e-prescribing mandate, B&P §688 (health care practitioners must have the capability to issue and transmit electronic data transmission prescriptions as of January 1, 2022)",
          "repaired": {
            "action": "replace",
            "evidence": "Health care practitioners authorized to issue prescriptions must have the capability to issue an electronic data transmission prescription and transmit it to a pharmacy selected by the patient. Pharmacies and dispensing practitioners must have the capability to receive electronic data transmission prescriptions. ... For controlled substance prescriptions, generation and transmission must comply with Parts 1300, 1304, 1306, and 1311 of Title 21 of the Code of Federal Regulations.",
            "ticket": "PROT-017",
            "was": {
              "source": "California e-prescribing mandate, B&P §688",
              "url": "https://oag.ca.gov/cures"
            }
          },
          "source": "CA Business and Professions Code §688",
          "url": "https://law.justia.com/codes/california/code-bpc/division-2/chapter-1/article-7-5/section-688/"
        },
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Part 1306 (prescription requirements)",
          "source": "DEA regulations 21 CFR Part 1306 (prescription requirements)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "rx-007",
      "kind": "clinical",
      "materials": [
        "e-prescribing system",
        "paper prescription pad (outage backup)",
        "phone log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify which scenario applies",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "send",
              "label": "New prescription ready to send"
            },
            {
              "goto": "s4",
              "id": "outage",
              "label": "E-prescribing system is down"
            },
            {
              "goto": "s5",
              "id": "callback",
              "label": "Pharmacy or patient calling about a refill or clarification"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "Identify which scenario applies"
        },
        {
          "detail": "E-prescribe per the CA mandate; confirm the transmission confirmation is received and filed.\n\nWhy: California requires electronic transmission except for specific statutory exceptions.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Send the prescription electronically",
          "why": "California requires electronic transmission except for specific statutory exceptions."
        },
        {
          "detail": "Prescribing action or callback completed and documented",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribing action or callback completed and documented"
        },
        {
          "detail": "Write the prescription on the paper pad per the statutory exception for technological failure; note the outage (system, start time) in the chart and follow up once e-prescribing is restored.\n\nWhy: The statute's outage exception requires documentation, not just a switch to paper without a record.\n\nRecord: Outage start/end time and paper-prescription use documented",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Use the paper fallback and document the outage",
          "why": "The statute's outage exception requires documentation, not just a switch to paper without a record."
        },
        {
          "detail": "Take the caller's name, pharmacy, patient, and question; never approve, deny, or characterize a refill or clarification without the dentist's decision.\n\nWhy: Only the prescriber may decide a refill or clarification question — this is a licensure boundary, not a courtesy.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Front desk intercepts the call and does not make the clinical decision",
          "why": "Only the prescriber may decide a refill or clarification question — this is a licensure boundary, not a courtesy."
        },
        {
          "detail": "Write down the caller's name, pharmacy, patient, and exact question in the call log for the dentist to review.\n\nRecord: Caller, pharmacy, patient, and question logged for the dentist",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the call details"
        },
        {
          "detail": "Dentist personally reviews the chart and the pharmacy's/patient's question, then decides whether to approve, deny, or modify.\n\nWhy: A refill decision is a prescribing act and cannot be delegated to non-licensed staff.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and decides the refill or clarification — never staff.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and decides the refill or clarification — never staff",
          "why": "A refill decision is a prescribing act and cannot be delegated to non-licensed staff."
        },
        {
          "detail": "Call the pharmacy back directly, or have front desk relay only the dentist's exact decision without adding interpretation.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Respond to the pharmacy or patient with the decision"
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "E-prescribing send, outage fallback and pharmacy or refill callback (dentist decides) — A prescription is sent, the e-prescribing system is down, or a pharmacy or patient calls with a refill or clarification question — the dentist decides, never staff.",
      "title": "E-prescribing send, outage fallback and pharmacy or refill callback (dentist decides)",
      "trigger": "A prescription is sent, the e-prescribing system is down, or a pharmacy or patient calls with a refill or clarification question — the dentist decides, never staff",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "source": "CDC Clinical Practice Guideline for Prescribing Opioids (2022)",
          "url": "https://www.cdc.gov/opioids/"
        },
        {
          "kind": "statute",
          "label": "California CURES mandatory consultation, H&S §11165.4",
          "source": "California CURES mandatory consultation, H&S §11165.4",
          "url": "https://oag.ca.gov/cures"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rx-008",
      "kind": "clinical",
      "materials": [
        "CURES/PDMP portal access",
        "chart / practice management system",
        "office boundary-setting script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "If the patient has called about lost pills, requested a specific opioid by name, or presented repeatedly, note it in the chart for the dentist to review before seeing the patient — front desk does not make any clinical judgment.\n\nWhy: Giving the dentist the pattern before the encounter supports an objective clinical assessment instead of an in-the-moment reaction.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Note the pattern and flag the chart for the dentist before the visit",
          "why": "Giving the dentist the pattern before the encounter supports an objective clinical assessment instead of an in-the-moment reaction."
        },
        {
          "detail": "Examine for an objective dental finding that would explain the reported pain, using radiographs as indicated.\n\nWhy: The clinical decision must rest on exam findings, not on how the request is phrased.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Perform an objective clinical exam independent of the patient's request",
          "why": "The clinical decision must rest on exam findings, not on how the request is phrased."
        },
        {
          "detail": "Query the state prescription drug monitoring program before making any prescribing decision.\n\nWhy: Objective controlled-substance history is more reliable than the visit narrative alone.\n\nRecord: PDMP query result recorded in chart",
          "gate": {
            "ack": "I confirm I have completed this step as written: Run the PDMP (CURES) check.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Run the PDMP (CURES) check",
          "why": "Objective controlled-substance history is more reliable than the visit narrative alone."
        },
        {
          "detail": "Does the exam and PDMP support an opioid prescription?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "no-finding",
              "label": "No objective finding, or PDMP shows a concerning pattern"
            },
            {
              "goto": "s9",
              "id": "finding-present",
              "label": "Objective finding supports a prescribing need per rx-002"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the exam and PDMP support an opioid prescription?"
        },
        {
          "detail": "Offer NSAID/acetaminophen per rx-001 and/or definitive dental treatment; explain to the patient, without accusation, that the exam and PDMP do not support an opioid today.\n\nWhy: A clear, respectful, clinically-grounded explanation sets a boundary while keeping the patient in care.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Offer a non-opioid pain-management plan and explain the reasoning",
          "why": "A clear, respectful, clinically-grounded explanation sets a boundary while keeping the patient in care."
        },
        {
          "detail": "Chart the exam findings, the PDMP result, and a summary of the non-opioid plan conversation with the patient.\n\nRecord: Exam findings, PDMP result, and the boundary-setting conversation documented in chart",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document the encounter, findings, PDMP result, and conversation"
        },
        {
          "detail": "Does the pattern warrant a practice-level policy discussion (e.g., dismissal, controlled-substance agreement)?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "no",
              "label": "No — single encounter handled"
            },
            {
              "goto": "s10",
              "id": "yes",
              "label": "Yes — repeated pattern across visits"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the pattern warrant a practice-level policy discussion (e.g., dismissal, controlled-substance agreement)?"
        },
        {
          "detail": "Encounter assessed, documented, and resolved without an unsupported opioid prescription",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Encounter assessed, documented, and resolved without an unsupported opioid prescription"
        },
        {
          "detail": "Proceed under rx-002 exactly as for any other patient — the exam and PDMP findings, not the initial suspicion, drive the decision.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Route to the standard opioid-prescribing-exception protocol"
        },
        {
          "detail": "Review the documented pattern with the dentist and decide on a formal controlled-substance agreement or, in rare cases, dismissal from the practice per standard dismissal procedure.\n\nWhy: A practice-level policy decision (agreement or dismissal) has legal and continuity-of-care implications beyond a single visit and belongs at the ownership/management level.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews whether a controlled-substance agreement or dismissal from care is warranted.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews whether a controlled-substance agreement or dismissal from care is warranted",
          "why": "A practice-level policy decision (agreement or dismissal) has legal and continuity-of-care implications beyond a single visit and belongs at the ownership/management level."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Suspected drug-seeking behavior — assessment, PDMP, non-opioid plan, boundaries — A patient reports lost pills, requests a specific opioid by name, or presents repeatedly with no findings.",
      "title": "Suspected drug-seeking behavior — assessment, PDMP, non-opioid plan, boundaries",
      "trigger": "A patient reports lost pills, requests a specific opioid by name, or presents repeatedly with no findings",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FDA MedWatch voluntary adverse-event reporting (Form 3500)",
          "source": "FDA MedWatch voluntary adverse-event reporting (Form 3500)",
          "url": "https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program"
        },
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rx-009",
      "kind": "clinical",
      "materials": [
        "chart / allergy list",
        "emergency kit",
        "FDA Form 3500",
        "phone"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "If the patient reports difficulty breathing, throat or facial swelling, chest pain, fainting, or is not reachable/responsive, call 911 (EMS) immediately and stay on the line; do not attempt to triage further before EMS is dispatched.\n\nWhy: Anaphylaxis and airway compromise can progress in minutes; the emergency call always comes before information-gathering.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Life-threatening reaction? Call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Life-threatening reaction? Call 911 first",
          "why": "Anaphylaxis and airway compromise can progress in minutes; the emergency call always comes before information-gathering."
        },
        {
          "detail": "Ask what drug, what symptom, when it started, and whether it is worsening.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "severe",
              "label": "Severe (911 already called, or breathing/swelling/fainting)"
            },
            {
              "goto": "s10",
              "id": "mild",
              "label": "Mild (rash, GI upset, itching, no airway involvement)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this reaction severe or mild?"
        },
        {
          "detail": "Interrupt the dentist's current patient (or page) with the caller's name, drug, symptom, and whether EMS is en route; hand the phone to the dentist.\n\nWhy: A severe reaction needs the licensed prescriber's judgment in real time, not a callback later.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to dentist immediately",
          "why": "A severe reaction needs the licensed prescriber's judgment in real time, not a callback later."
        },
        {
          "detail": "For a reaction severe enough that EMS was called, advise using an epinephrine auto-injector immediately if one is available, in addition to stopping the drug; antihistamine is an adjunct, not a substitute for epinephrine. Confirm the patient will be seen by EMS or an ER.\n\nWhy: The prescriber owns clinical management of a reaction to a drug they prescribed.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Assess and manage on the phone or in person",
          "why": "The prescriber owns clinical management of a reaction to a drug they prescribed."
        },
        {
          "detail": "The dentist reviews and signs the chart note describing the reaction, the drug implicated, and the new allergy/intolerance flag before it is filed.\n\nWhy: An allergy flag drives every future prescription decision, so a licensed clinician must confirm it before it becomes permanent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on chart entry and allergy flag.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on chart entry and allergy flag",
          "why": "An allergy flag drives every future prescription decision, so a licensed clinician must confirm it before it becomes permanent."
        },
        {
          "detail": "Serious, unexpected, or unlabeled reactions are candidates for voluntary reporting; reactions already listed on the drug label as common and non-serious usually are not.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "report",
              "label": "File FDA Form 3500 (voluntary)"
            },
            {
              "goto": "s8",
              "id": "no-report",
              "label": "Chart only — known, labeled, non-serious reaction"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Report to FDA MedWatch?"
        },
        {
          "detail": "Complete and submit the voluntary MedWatch report online with drug, dose, reaction, timeline and outcome; keep a copy of the submission confirmation.\n\nWhy: Voluntary reports build the national adverse-event signal that later changes labeling and guidance.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Submit FDA Form 3500",
          "why": "Voluntary reports build the national adverse-event signal that later changes labeling and guidance."
        },
        {
          "detail": "File the chart note, allergy flag, and (if filed) the MedWatch confirmation number in the patient record and the practice's incident log.\n\nRecord: Reaction description, drug implicated, management given, allergy flag, and any MedWatch confirmation number.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Close out the incident record"
        },
        {
          "detail": "Adverse reaction closed",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Adverse reaction closed"
        },
        {
          "detail": "Record the drug, dose, timing, symptom and patient contact number; place in the dentist's callback queue for same business day.\n\nWhy: Mild reactions still need licensed review, but do not require interrupting active patient care.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Log details and route to dentist for same-day callback",
          "why": "Mild reactions still need licensed review, but do not require interrupting active patient care."
        },
        {
          "detail": "Instruct the patient to discontinue the suspected drug, document the reaction as a new allergy/intolerance in the chart, and offer an alternative if treatment is still needed.\n\nWhy: Even a mild reaction becomes a permanent allergy flag so it is never re-prescribed.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Advise on stopping/switching the drug",
          "why": "Even a mild reaction becomes a permanent allergy flag so it is never re-prescribed."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Adverse drug reaction — recognition, management and voluntary reporting — A patient reports a reaction to a prescribed or administered drug.",
      "title": "Adverse drug reaction — recognition, management and voluntary reporting",
      "trigger": "A patient reports a reaction to a prescribed or administered drug",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California CURES mandatory consultation H&S §11165.4; e-prescribing B&P §688; naloxone offer B&P §740",
          "source": "California CURES mandatory consultation H&S §11165.4; e-prescribing B&P §688; naloxone offer B&P §740",
          "url": "https://oag.ca.gov/cures"
        },
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "rx-010",
      "kind": "clinical",
      "materials": [
        "e-prescribing terminal",
        "chart",
        "pharmacy phone number",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Pull up the prescription record in the e-prescribing system and confirm exactly what drug, dose, quantity and patient it was sent under, and what it should have been.\n\nWhy: Correction has to start from the exact record that went out, not from memory of what was intended.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the error and what was sent",
          "why": "Correction has to start from the exact record that went out, not from memory of what was intended."
        },
        {
          "detail": "Wrong drug, wrong dose, wrong patient, or a controlled-substance quantity error are high risk; a typo that does not change clinical meaning (e.g. address) is low risk.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "high-risk",
              "label": "High risk — could cause harm if filled as sent"
            },
            {
              "goto": "s6",
              "id": "low-risk",
              "label": "Low risk — clerical only, no clinical change"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Could this error cause patient harm if filled?"
        },
        {
          "detail": "Call the receiving pharmacy directly, identify the prescriber and patient, and ask them to hold or cancel the fill before it is dispensed; follow with an electronic cancellation if the system supports it.\n\nWhy: A phone call reaches the pharmacist faster than an electronic cancel message during business hours, and confirms a human actually intercepted it.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Call the pharmacy immediately to hold or cancel",
          "why": "A phone call reaches the pharmacist faster than an electronic cancel message during business hours, and confirms a human actually intercepted it."
        },
        {
          "detail": "Ask the pharmacist whether the patient already picked it up.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "not-dispensed",
              "label": "Not dispensed — held or cancelled"
            },
            {
              "goto": "s10",
              "id": "already-dispensed",
              "label": "Already dispensed to the patient"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Was the prescription already dispensed?"
        },
        {
          "detail": "Issue a new, correct e-prescription to the same pharmacy and confirm receipt.\n\nWhy: The patient still needs the medication they actually require, once the wrong one is stopped.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Send the corrected prescription",
          "why": "The patient still needs the medication they actually require, once the wrong one is stopped."
        },
        {
          "detail": "Write a factual chart note: what was sent in error, when discovered, who was notified (pharmacy, patient), and the corrected prescription sent, with times.\n\nRecord: Error description, discovery time, notifications made, and corrected prescription details.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document the error and correction in the chart"
        },
        {
          "detail": "The prescribing dentist reviews and signs the completed error record before it is filed as closed.\n\nWhy: A prescription error is a licensure-relevant event that the prescriber of record must personally confirm was handled correctly.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the incident record.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the incident record",
          "why": "A prescription error is a licensure-relevant event that the prescriber of record must personally confirm was handled correctly."
        },
        {
          "detail": "Log the error type and root cause (wrong patient selected, wrong dose default, look-alike drug names, etc.) in the practice's running incident log for trend review.\n\nWhy: A generic administrative practice pattern for catching repeat error causes before they recur — borrowed from standard error-tracking, not a dental-specific rule.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Add to the practice incident log",
          "why": "A generic administrative practice pattern for catching repeat error causes before they recur — borrowed from standard error-tracking, not a dental-specific rule."
        },
        {
          "detail": "Prescription error closed",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Prescription error closed"
        },
        {
          "detail": "Explain the error in plain language, what the correct medication or dose is, and what to do with what they already have (do not take / return to pharmacy / take as corrected).\n\nWhy: The patient has to hear from the prescriber, not front desk, when a drug already in their hands is wrong.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Call the patient directly",
          "why": "The patient has to hear from the prescriber, not front desk, when a drug already in their hands is wrong."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Prescription error — cancel, correct, notify pharmacy and patient, document — A wrong drug, dose or patient is discovered after a prescription is sent.",
      "title": "Prescription error — cancel, correct, notify pharmacy and patient, document",
      "trigger": "A wrong drug, dose or patient is discovered after a prescription is sent",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "rx-011",
      "kind": "clinical",
      "materials": [
        "DEA registration certificate",
        "state dental license",
        "DEA online registration portal login"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Identify whether this is a routine renewal, a practice relocation, or a new prescriber joining.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "renewal",
              "label": "Three-year renewal notice received"
            },
            {
              "goto": "s7",
              "id": "relocation",
              "label": "Practice is relocating"
            },
            {
              "goto": "s8",
              "id": "new-prescriber",
              "label": "New prescriber joining"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "What triggered this?"
        },
        {
          "detail": "Check that the registered address, business activity, and drug schedules on file still match the practice's actual operations.\n\nWhy: Renewing a registration with stale details just re-files the same error for another three years.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm registration details before renewing",
          "why": "Renewing a registration with stale details just re-files the same error for another three years."
        },
        {
          "detail": "Complete and submit the DEA renewal application through the registration portal well before the expiration date shown on the notice.\n\nWhy: A lapsed registration means the practice cannot lawfully order, possess, or prescribe controlled substances until reinstated.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the renewal application",
          "why": "A lapsed registration means the practice cannot lawfully order, possess, or prescribe controlled substances until reinstated."
        },
        {
          "detail": "The registrant dentist reviews the submitted or updated registration details for accuracy before the application is finalized.\n\nWhy: The registration is issued to the individual prescriber, who is personally accountable for its accuracy.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms registration accuracy before filing.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms registration accuracy before filing",
          "why": "The registration is issued to the individual prescriber, who is personally accountable for its accuracy."
        },
        {
          "detail": "Save the confirmation/certificate and enter the new expiration date into the compliance tracking calendar.\n\nRecord: Registration confirmation number, effective date, and new expiration date.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "File the confirmation and update the compliance calendar"
        },
        {
          "detail": "Registration current",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Registration current"
        },
        {
          "detail": "Submit a change-of-address application before controlled substances are stored or dispensed at the new location.\n\nWhy: The registration is tied to a specific registered location; storing controlled substances at an unregistered address is a separate violation.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "File the address/location change",
          "why": "The registration is tied to a specific registered location; storing controlled substances at an unregistered address is a separate violation."
        },
        {
          "detail": "Confirm the incoming dentist holds an active, individually registered DEA number valid for this state before they write any controlled-substance prescription from this location.\n\nWhy: DEA registration is per-individual-prescriber, not per-practice; a practice's registration does not cover a new dentist's prescribing.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm or initiate the new prescriber's own registration",
          "why": "DEA registration is per-individual-prescriber, not per-practice; a practice's registration does not cover a new dentist's prescribing."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "DEA registration renewal and address or schedule change — The three-year renewal notice arrives, the practice relocates, or a new prescriber joins.",
      "title": "DEA registration renewal and address or schedule change",
      "trigger": "The three-year renewal notice arrives, the practice relocates, or a new prescriber joins",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rx-012",
      "kind": "clinical",
      "materials": [
        "DEA Form 222 or CSOS electronic ordering credentials",
        "supplier account",
        "perpetual inventory log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm the specific drug, strength, and quantity needed for the emergency kit or sedation stock, checking current on-hand count against the reorder threshold.\n\nWhy: Schedule II orders cannot be casually adjusted after submission, so the quantity has to be right the first time.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify the Schedule II item and quantity needed",
          "why": "Schedule II orders cannot be casually adjusted after submission, so the quantity has to be right the first time."
        },
        {
          "detail": "The DEA registrant dentist reviews and approves the item and quantity before the order is placed; only the registrant (or their authorized power-of-attorney designee) may sign a Form 222 or execute a CSOS order.\n\nWhy: Only the registrant, or someone they have formally granted power of attorney to order for them, may lawfully order Schedule II drugs.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Registrant dentist authorizes the order.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Registrant dentist authorizes the order",
          "why": "Only the registrant, or someone they have formally granted power of attorney to order for them, may lawfully order Schedule II drugs."
        },
        {
          "detail": "Choose the ordering method the practice has set up with its supplier.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "csos",
              "label": "Electronic order via CSOS"
            },
            {
              "goto": "s9",
              "id": "form222",
              "label": "Paper DEA Form 222"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Paper Form 222 or electronic (CSOS)?"
        },
        {
          "detail": "Log in with the registrant's CSOS digital certificate and submit the order to the registered supplier.\n\nWhy: CSOS orders are digitally signed by the registrant's own certificate, which is the electronic equivalent of the Form 222 signature.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the electronic order",
          "why": "CSOS orders are digitally signed by the registrant's own certificate, which is the electronic equivalent of the Form 222 signature."
        },
        {
          "detail": "Track the order until it arrives; standard supplier lead time is typically several business days.\n\nWhy: Ordering is only the first half of the controlled record — the item must be tracked until receiving closes the loop.",
          "id": "s5",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 259200,
          "title": "Await shipment",
          "why": "Ordering is only the first half of the controlled record — the item must be tracked until receiving closes the loop."
        },
        {
          "detail": "When the shipment arrives, route it directly into the controlled-substance receiving and perpetual-log protocol (rx-013) rather than general supply intake.\n\nWhy: Controlled substances must never sit in general supply intake — receipt has to be logged the moment it arrives.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the receiving protocol on arrival",
          "why": "Controlled substances must never sit in general supply intake — receipt has to be logged the moment it arrives."
        },
        {
          "detail": "Retain the Form 222 file copy or CSOS confirmation with the order date, item, quantity and supplier for the required retention period.\n\nRecord: Order form/confirmation number, item, quantity, supplier, and date ordered.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "File the order record"
        },
        {
          "detail": "Order placed and filed",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Order placed and filed"
        },
        {
          "detail": "Fill out DEA Form 222 with item, quantity and date, obtain the registrant's original signature, and send copies per the form's instructions (supplier copy and file copy retained).\n\nWhy: A Form 222 with an incomplete or non-registrant signature is void and must be reordered, delaying supply.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete and submit the paper form",
          "why": "A Form 222 with an incomplete or non-registrant signature is void and must be reordered, delaying supply."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Ordering Schedule II drugs via Form 222 or the electronic ordering system — The emergency kit or sedation stock needs a Schedule II item.",
      "title": "Ordering Schedule II drugs via Form 222 or the electronic ordering system",
      "trigger": "The emergency kit or sedation stock needs a Schedule II item",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "rx-013",
      "kind": "clinical",
      "materials": [
        "shipment / packing slip",
        "perpetual inventory log",
        "double-locked storage cabinet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "office-manager",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Move the unopened shipment directly to a secure area (not the general front-desk mail pile) and do not leave it unattended.\n\nWhy: A controlled-substance shipment sitting in an open area between arrival and logging is an uncontrolled window for loss.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Isolate the shipment on arrival",
          "why": "A controlled-substance shipment sitting in an open area between arrival and logging is an uncontrolled window for loss."
        },
        {
          "detail": "Open in the presence of a second staff member; count each item and compare against the packing slip and the original order.\n\nWhy: A two-person count at receiving is the point where a shortage is easiest to catch — before the item enters inventory unchallenged.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Verify contents against the packing slip",
          "why": "A two-person count at receiving is the point where a shortage is easiest to catch — before the item enters inventory unchallenged."
        },
        {
          "detail": "Compare received quantity to ordered and listed quantity.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "matches",
              "label": "Count matches"
            },
            {
              "goto": "s8",
              "id": "mismatch",
              "label": "Discrepancy found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the count match the packing slip and order?"
        },
        {
          "detail": "Enter date received, drug name, strength, quantity, supplier, and running balance into the perpetual log, in ink or a tamper-evident electronic system.\n\nWhy: The perpetual log has to reflect every unit from the moment it enters the practice, with no gap between receiving and logging.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Record the receipt in the perpetual inventory log",
          "why": "The perpetual log has to reflect every unit from the moment it enters the practice, with no gap between receiving and logging."
        },
        {
          "detail": "Place the received stock into the designated double-locked cabinet or safe immediately after logging; do not leave it accessible on a counter or in a single-locked drawer.\n\nWhy: Storage security requirements exist specifically to prevent the receiving-to-storage gap from being an access opportunity.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Place into double-locked, substantially constructed storage",
          "why": "Storage security requirements exist specifically to prevent the receiving-to-storage gap from being an access opportunity."
        },
        {
          "detail": "The registrant dentist (or their documented power-of-attorney designee) reviews and initials the new log entry before the shift ends.\n\nWhy: The registrant is personally accountable for the accuracy of the controlled-substance record, even when staff perform the physical receiving.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist or designated registrant confirms the log entry.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist or designated registrant confirms the log entry",
          "why": "The registrant is personally accountable for the accuracy of the controlled-substance record, even when staff perform the physical receiving."
        },
        {
          "detail": "Shipment received, logged and secured",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Shipment received, logged and secured"
        },
        {
          "detail": "A shortage discovered at receiving is handed to rx-016 (theft or significant loss) rather than logged as received; contact the supplier separately to resolve the shipping discrepancy.\n\nWhy: A count mismatch at first receipt still has to go through the same accountability process as a mismatch found later.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the theft-or-loss protocol",
          "why": "A count mismatch at first receipt still has to go through the same accountability process as a mismatch found later."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Receiving controlled substances and recording into the perpetual log — A controlled-substance shipment arrives at the front desk.",
      "title": "Receiving controlled substances and recording into the perpetual log",
      "trigger": "A controlled-substance shipment arrives at the front desk",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "rx-014",
      "kind": "clinical",
      "materials": [
        "perpetual inventory log",
        "physical count sheet",
        "storage cabinet keys/codes",
        "access roster"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Identify whether this cycle is the full physical inventory (every two years, or triggered by a schedule/registration change) or the routine monthly storage and access review.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "biennial",
              "label": "Biennial (or triggered) full physical inventory"
            },
            {
              "goto": "s7",
              "id": "monthly",
              "label": "Monthly storage/access review"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Biennial inventory due, or a monthly/event-driven review?"
        },
        {
          "detail": "Count every Schedule II item exactly; Schedule III–V items may be estimated unless the container holds more than 1,000 units, per DEA rules — record the count date and time.\n\nWhy: The exact-count-vs-estimate distinction is a specific DEA inventory rule, not an office preference.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Conduct a physical count of every controlled substance on hand",
          "why": "The exact-count-vs-estimate distinction is a specific DEA inventory rule, not an office preference."
        },
        {
          "detail": "Compare the physical count to the running balance in the perpetual inventory log.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "matches",
              "label": "Matches"
            },
            {
              "goto": "s9",
              "id": "mismatch",
              "label": "Discrepancy found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the physical count match the perpetual log?"
        },
        {
          "detail": "Sign, date, and retain the inventory record for the required retention period; calendar the next biennial due date.\n\nRecord: Inventory date, items counted, quantities, and reconciliation result against the perpetual log.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the completed inventory record"
        },
        {
          "detail": "The registrant dentist or the designated compliance officer reviews and signs the completed inventory or monthly review record.\n\nWhy: Registration-holder accountability for the controlled-substance record does not delegate away, even for a routine monthly check.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist or compliance officer signs off.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist or compliance officer signs off",
          "why": "Registration-holder accountability for the controlled-substance record does not delegate away, even for a routine monthly check."
        },
        {
          "detail": "Inventory/review closed",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Inventory/review closed"
        },
        {
          "detail": "Confirm the storage cabinet or safe still has two independent locking mechanisms in working order and is inside a substantially constructed, monitored area.\n\nWhy: Locks and cabinets degrade or get propped open under daily use; the requirement is that the security actually works, not just that a cabinet exists.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify double-lock storage integrity",
          "why": "Locks and cabinets degrade or get propped open under daily use; the requirement is that the security actually works, not just that a cabinet exists."
        },
        {
          "detail": "Confirm the current access roster (key holders, code holders) matches only currently employed staff with a legitimate need; remove access for anyone separated or reassigned.\n\nWhy: Access has to shrink the moment someone leaves — stale access is the single most common gap the theft/loss protocol traces back to.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Review who has access",
          "why": "Access has to shrink the moment someone leaves — stale access is the single most common gap the theft/loss protocol traces back to."
        },
        {
          "detail": "Hand any unexplained shortage to rx-016 (theft or significant loss) rather than closing out the inventory as matched.\n\nWhy: An inventory discrepancy is exactly the trigger the theft/loss protocol exists to catch.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Escalate to the theft-or-loss protocol",
          "why": "An inventory discrepancy is exactly the trigger the theft/loss protocol exists to catch."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Biennial controlled-substance inventory and monthly double-lock storage and access review — Two years since the last inventory, a schedule change, a lock change, or a staff member with access separates.",
      "title": "Biennial controlled-substance inventory and monthly double-lock storage and access review",
      "trigger": "Two years since the last inventory, a schedule change, a lock change, or a staff member with access separates",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "rx-015",
      "kind": "clinical",
      "materials": [
        "expired/unwanted stock",
        "reverse distributor account",
        "perpetual inventory log",
        "DEA Form 41 (if applicable)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pull the item from active stock, note it in the perpetual log as removed for disposal (not dispensed), and segregate it in the double-locked storage away from active stock.\n\nWhy: An expired unit still counts against the controlled inventory until it is formally disposed of — it cannot just be set aside untracked.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify expired or unwanted controlled stock",
          "why": "An expired unit still counts against the controlled inventory until it is formally disposed of — it cannot just be set aside untracked."
        },
        {
          "detail": "A DEA-registered reverse distributor is the standard route for practice stock; on-site destruction is not permitted without separate DEA authorization.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "reverse-distributor",
              "label": "DEA-registered reverse distributor pickup/mail-back"
            },
            {
              "goto": "s9",
              "id": "other",
              "label": "Other DEA-authorized method"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "How will this be disposed of?"
        },
        {
          "detail": "Contact the registered reverse distributor to arrange pickup or an authorized mail-back package for the segregated stock.\n\nWhy: Reverse distributors are separately DEA-registered for this exact purpose, closing the chain of custody legally.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the reverse distributor",
          "why": "Reverse distributors are separately DEA-registered for this exact purpose, closing the chain of custody legally."
        },
        {
          "detail": "Record item, quantity, date, and the reverse distributor's receipt or tracking confirmation at the moment custody transfers.\n\nWhy: The practice's chain-of-custody record ends the moment the reverse distributor takes possession — that handoff has to be documented precisely.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the transfer at handoff",
          "why": "The practice's chain-of-custody record ends the moment the reverse distributor takes possession — that handoff has to be documented precisely."
        },
        {
          "detail": "Close out the item's balance in the perpetual log, referencing the disposal transaction and reverse distributor confirmation.\n\nWhy: The perpetual log must show zero balance for a disposed item, with a clear paper trail explaining why.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Update the perpetual inventory log",
          "why": "The perpetual log must show zero balance for a disposed item, with a clear paper trail explaining why."
        },
        {
          "detail": "The registrant dentist reviews and signs the completed disposal record before it is filed.\n\nWhy: Disposal closes out controlled inventory the registrant is personally accountable for.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the disposal record.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the disposal record",
          "why": "Disposal closes out controlled inventory the registrant is personally accountable for."
        },
        {
          "detail": "Retain the reverse distributor's certificate of destruction/transfer with the perpetual log entry for the required retention period.\n\nRecord: Item, quantity, disposal date, reverse distributor confirmation/certificate number.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the disposal certificate"
        },
        {
          "detail": "Disposal complete and documented",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Disposal complete and documented"
        },
        {
          "detail": "The registrant dentist confirms in writing that the alternative disposal method is authorized under current DEA regulation before any stock leaves the practice.\n\nWhy: Disposing of controlled substances outside an authorized channel is itself a regulatory violation, so this has to be confirmed before, not after.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm any non-reverse-distributor method is DEA-authorized before proceeding.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm any non-reverse-distributor method is DEA-authorized before proceeding",
          "why": "Disposing of controlled substances outside an authorized channel is itself a regulatory violation, so this has to be confirmed before, not after."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Disposal of expired or unwanted controlled substances via reverse distributor — A controlled drug in stock expires or is discontinued.",
      "title": "Disposal of expired or unwanted controlled substances via reverse distributor",
      "trigger": "A controlled drug in stock expires or is discontinued",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "rx-016",
      "kind": "clinical",
      "materials": [
        "perpetual inventory log",
        "DEA Form 106",
        "local police non-emergency line",
        "state dental board contact",
        "incident log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "compliance-officer",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If a break-in, armed intruder, or any threat to staff or patient safety is in progress or just discovered, call 911 (EMS/police) immediately and get everyone to safety before touching anything in the area.\n\nWhy: Personal safety and an active scene always come before securing records or drugs.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Active break-in or threat in progress? Call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Active break-in or threat in progress? Call 911 first",
          "why": "Personal safety and an active scene always come before securing records or drugs."
        },
        {
          "detail": "If police are involved, do not touch the storage cabinet, log, or surrounding area until police have documented the scene; if this is an inventory discrepancy with no break-in, secure remaining stock immediately.\n\nWhy: Disturbing a break-in scene can compromise a police investigation; leaving remaining stock unsecured compounds the loss.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Secure the area without disturbing evidence",
          "why": "Disturbing a break-in scene can compromise a police investigation; leaving remaining stock unsecured compounds the loss."
        },
        {
          "detail": "Perform an immediate physical count and compare against the perpetual log to determine exactly what is missing and in what quantity.\n\nWhy: The DEA report has to state precisely what and how much is missing, which requires the reconciliation to happen before filing, not after.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Reconcile the perpetual log against physical count",
          "why": "The DEA report has to state precisely what and how much is missing, which requires the reconciliation to happen before filing, not after."
        },
        {
          "detail": "Any theft is reportable; for loss, consider quantity, drug schedule, likelihood of diversion vs. simple record error, and pattern (repeated small discrepancies can add up to significant).",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "significant",
              "label": "Theft, or a significant/suspicious loss"
            },
            {
              "goto": "s14",
              "id": "minor-correctable",
              "label": "Minor, clearly explainable record/counting error"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this a significant loss requiring DEA reporting?"
        },
        {
          "detail": "Contact local police (non-emergency line if the scene is already secure) to file a theft report; obtain the report or case number.\n\nWhy: A police report number is typically required on the DEA Form 106 and is the practice's own record that theft was reported promptly.",
          "id": "s5",
          "kind": "step",
          "role": "practice-owner",
          "title": "File a police report",
          "why": "A police report number is typically required on the DEA Form 106 and is the practice's own record that theft was reported promptly."
        },
        {
          "detail": "Complete and submit DEA Form 106 online (Report of Theft or Loss of Controlled Substances) describing the drug, quantity, circumstances, and the police case number if filed.\n\nWhy: One business day is the regulatory deadline from the moment the loss is discovered, not from when the investigation concludes.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File DEA Form 106 within one business day of discovery",
          "why": "One business day is the regulatory deadline from the moment the loss is discovered, not from when the investigation concludes."
        },
        {
          "detail": "Check the state dental board's reporting requirement for controlled-substance loss or theft and file if required, in addition to the DEA report.\n\nWhy: State board reporting is a separate obligation from the federal DEA report and has its own timeline.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the state dental board if required",
          "why": "State board reporting is a separate obligation from the federal DEA report and has its own timeline."
        },
        {
          "detail": "The registrant dentist reviews and signs the completed incident file, including any internal findings on cause, before it moves to the practice owner for final closure.\n\nWhy: A theft or significant loss carries licensure exposure that the registrant must confirm personally before the incident is closed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Registrant dentist signs off on the incident file.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Registrant dentist signs off on the incident file",
          "why": "A theft or significant loss carries licensure exposure that the registrant must confirm personally before the incident is closed."
        },
        {
          "detail": "The practice owner reviews and signs the completed incident file after the registrant dentist's sign-off, closing out the business-risk side of the record.\n\nWhy: A theft or significant loss carries business risk alongside licensure risk, so both the registrant and the owner formally close the record.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner signs off before closing.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner signs off before closing",
          "why": "A theft or significant loss carries business risk alongside licensure risk, so both the registrant and the owner formally close the record."
        },
        {
          "detail": "Consider whether access patterns, timing, or the nature of the loss point to a specific staff member or a systemic access-control gap.",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "yes",
              "label": "Yes — hand off to diversion-suspicion investigation"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "No — shipping/counting error confirmed, no staff suspicion"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Does this warrant an internal staff investigation?"
        },
        {
          "detail": "Route this incident into rx-018 (suspected staff diversion) for a formal internal investigation, kept separate from this closed regulatory-reporting record.\n\nWhy: Regulatory reporting and internal personnel investigation are separate tracks that should not be conflated in one record.",
          "id": "s11",
          "kind": "step",
          "role": "practice-owner",
          "title": "Hand off to the staff diversion-suspicion protocol",
          "why": "Regulatory reporting and internal personnel investigation are separate tracks that should not be conflated in one record."
        },
        {
          "detail": "Retain the DEA Form 106 confirmation, police report number, board notification (if any), and reconciliation worksheet together for the required retention period.\n\nRecord: Item and quantity lost, discovery date, DEA Form 106 confirmation, police case number, board notification status.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the complete incident record"
        },
        {
          "detail": "Theft/loss incident closed",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Theft/loss incident closed"
        },
        {
          "detail": "Enter a corrected balance with a clear written explanation of the counting or recording error, initialed by the person who found and the person who corrected it.\n\nWhy: Not every discrepancy is theft, but every discrepancy needs a documented, attributable explanation — an unexplained correction is itself a red flag.",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Correct the log with a documented explanation",
          "why": "Not every discrepancy is theft, but every discrepancy needs a documented, attributable explanation — an unexplained correction is itself a red flag."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Theft or significant loss of controlled substances — DEA Form 106 within one business day, police and board — An inventory count does not match the log, or a break-in involves the drug cabinet.",
      "title": "Theft or significant loss of controlled substances — DEA Form 106 within one business day, police and board",
      "trigger": "An inventory count does not match the log, or a break-in involves the drug cabinet",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        },
        {
          "kind": "generic",
          "label": "State dental board reporting of suspected prescription fraud — requirements vary by state; addressed generically here as a functional equivalent of the DEA/board reporting duty",
          "source": "State dental board reporting of suspected prescription fraud — requirements vary by state; addressed generically here as a functional equivalent of the DEA/board reporting duty"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "rx-017",
      "kind": "clinical",
      "materials": [
        "prescription record / e-prescribing log",
        "pharmacy callback number",
        "incident log",
        "state dental board contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Write down the patient name, drug, strength, quantity, date, and the prescriber name as printed on the prescription; do not confirm the prescription is legitimate before the dentist checks the record.\n\nWhy: Front desk cannot verify authenticity from memory, and a premature confirmation could validate a forged document.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the pharmacist's call without confirming or denying anything",
          "why": "Front desk cannot verify authenticity from memory, and a premature confirmation could validate a forged document."
        },
        {
          "detail": "Pass the pharmacist's callback number and the prescription details to the dentist named on the document for same-day review.\n\nWhy: Only the named prescriber can confirm whether they actually wrote it.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand the details to the prescribing dentist",
          "why": "Only the named prescriber can confirm whether they actually wrote it."
        },
        {
          "detail": "Search the e-prescribing system and the patient's chart for a matching prescription on the date, drug, and quantity given by the pharmacist.\n\nWhy: The office's own record is the ground truth for whether this prescription was ever written.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Check the e-prescribing log and chart",
          "why": "The office's own record is the ground truth for whether this prescription was ever written."
        },
        {
          "detail": "Compare drug, dose, quantity, date and patient against the office record.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "confirmed-legit",
              "label": "Matches — this is a legitimate prescription"
            },
            {
              "goto": "s8",
              "id": "not-legitimate",
              "label": "No matching record, or details have been altered"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the prescription match a record the dentist actually wrote?"
        },
        {
          "detail": "Call the pharmacist directly and confirm the prescription details match the office record.\n\nWhy: The pharmacist needs the confirmation directly from the prescriber before dispensing.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Call the pharmacy back to confirm it is legitimate",
          "why": "The pharmacist needs the confirmation directly from the prescriber before dispensing."
        },
        {
          "detail": "File the pharmacist's callback details, the verification outcome, and any report case numbers together in the practice incident log.\n\nRecord: Pharmacy name and callback, prescription details, verification outcome, chart flag status, and any police/board case numbers.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Close out the incident record"
        },
        {
          "detail": "Forged/altered prescription call closed",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Forged/altered prescription call closed"
        },
        {
          "detail": "Call the pharmacist back and state plainly that the office did not write this prescription, or that it has been altered from what was written; ask them to hold or refuse the fill and retain the physical document or a copy of the electronic record.\n\nWhy: The pharmacist is the only party who can stop the fill in real time, so the correction has to reach them directly and promptly.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Tell the pharmacist it is not legitimate",
          "why": "The pharmacist is the only party who can stop the fill in real time, so the correction has to reach them directly and promptly."
        },
        {
          "detail": "Look up whether the named patient has a chart at the practice at all, and if so whether they have a recent legitimate visit that could explain a stolen prescription pad or credential rather than intentional fraud by the patient.\n\nWhy: An unknown name versus an existing patient changes what the practice reports and to whom.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Check whether this is an existing patient",
          "why": "An unknown name versus an existing patient changes what the practice reports and to whom."
        },
        {
          "detail": "The compliance officer confirms the forgery finding is documented with the pharmacy's callback details before any report is filed with police or the state board.\n\nWhy: A police or board report is a formal, consequential step that needs a documented basis before it is filed, not just a phone call's recollection.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off before reporting to authorities.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off before reporting to authorities",
          "why": "A police or board report is a formal, consequential step that needs a documented basis before it is filed, not just a phone call's recollection."
        },
        {
          "detail": "A confirmed forged or altered prescription is normally reportable; a single ambiguous case involving an established patient with no clear fraud intent may warrant a chart flag only pending more information.",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "report-authorities",
              "label": "Report to police and/or state board"
            },
            {
              "goto": "s13",
              "id": "chart-flag-only",
              "label": "Chart flag only — insufficient basis to report yet"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Report to police and/or the state board?"
        },
        {
          "detail": "File a police report (obtain a case number) and notify the state dental board if the state requires reporting of suspected prescription fraud.\n\nWhy: Prescription forgery is a controlled-substance fraud event with both criminal and licensure dimensions.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the police and/or board report",
          "why": "Prescription forgery is a controlled-substance fraud event with both criminal and licensure dimensions."
        },
        {
          "detail": "Add a prescription-fraud alert to the patient's chart noting the incident, and require any future prescription for this patient to follow an in-person, documented visit before it is written.\n\nWhy: A chart flag prevents the same pattern from succeeding again through a different pharmacy.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Flag the patient chart",
          "why": "A chart flag prevents the same pattern from succeeding again through a different pharmacy."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Pharmacy call about a forged or altered prescription — A pharmacist calls to verify a prescription the office did not write or that has been altered.",
      "title": "Pharmacy call about a forged or altered prescription",
      "trigger": "A pharmacist calls to verify a prescription the office did not write or that has been altered",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        },
        {
          "kind": "generic",
          "label": "Confidential internal personnel investigation procedure — a generic HR/employment-law functional equivalent, not a dental-specific rule; described in words here — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Confidential internal personnel investigation procedure — a generic HR/employment-law functional equivalent, not a dental-specific rule; described in words here"
          },
          "source": "Confidential internal personnel investigation procedure — a generic HR/employment-law functional equivalent, not a dental-specific rule; described in words here — Practice policy — no published authority governs this step."
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "rx-018",
      "kind": "clinical",
      "materials": [
        "perpetual inventory log",
        "access roster / key or code log",
        "HR file",
        "incident log",
        "HR or employment-law resource contact"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "compliance-officer",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If a staff member currently appears impaired and is scheduled for or performing patient care, or there is any immediate risk of a volatile confrontation, call 911 and immediately remove that person from all patient contact and controlled-substance access before doing anything else.\n\nWhy: An impaired staff member near patients or controlled substances is an active safety risk that outranks any investigation step.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Immediate danger — impaired staff or confrontation risk? Call 911 first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Immediate danger — impaired staff or confrontation risk? Call 911 first",
          "why": "An impaired staff member near patients or controlled substances is an active safety risk that outranks any investigation step."
        },
        {
          "detail": "Photograph or otherwise capture the current state of the perpetual log, any tampered packaging, and the access roster before anything is moved or corrected, without alerting the suspected individual.\n\nWhy: Evidence handled after word gets out is worth far less than evidence captured at first discovery.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Preserve the evidence quietly",
          "why": "Evidence handled after word gets out is worth far less than evidence captured at first discovery."
        },
        {
          "detail": "Brief the practice owner and the registrant dentist privately with what was found, without discussing it with other staff.\n\nWhy: This decision needs both business (owner) and licensure (registrant) authority before it goes further.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hand findings to the practice owner and registrant dentist",
          "why": "This decision needs both business (owner) and licensure (registrant) authority before it goes further."
        },
        {
          "detail": "The practice owner confirms that this moves forward as a confidential personnel investigation, with no confrontation or accusation made until findings are reviewed.\n\nWhy: An early confrontation on unverified suspicion can tip off an actual diverter to destroy evidence, or wrongly damage an innocent employee.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the investigation proceeds confidentially.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Confirm the investigation proceeds confidentially",
          "why": "An early confrontation on unverified suspicion can tip off an actual diverter to destroy evidence, or wrongly damage an innocent employee."
        },
        {
          "detail": "Weigh the complexity and stakes — termination decisions tied to suspected diversion carry real employment-law exposure.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "consult-outside",
              "label": "Consult HR/employment-law resource before any confrontation"
            },
            {
              "goto": "s15",
              "id": "proceed-internal",
              "label": "Proceed with internal review only"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Consult outside HR/employment counsel before proceeding?"
        },
        {
          "detail": "Contact the practice's HR consultant or employment attorney and describe the situation before any employee interview or access change is communicated.\n\nWhy: A wrongly handled personnel investigation can turn a controlled-substance problem into a separate employment-law problem.",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "Engage the HR/employment-law resource",
          "why": "A wrongly handled personnel investigation can turn a controlled-substance problem into a separate employment-law problem."
        },
        {
          "detail": "Quietly remove or change the individual's controlled-substance cabinet keys or codes pending investigation, using a routine-sounding reason (e.g. a general access review) rather than revealing the suspicion.\n\nWhy: Access has to be cut before the investigation proceeds, or the exposure continues while the review runs.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Restrict the suspected individual's access",
          "why": "Access has to be cut before the investigation proceeds, or the exposure continues while the review runs."
        },
        {
          "detail": "Check: shift and access-log correlation with discrepancy timing; any available video coverage of the storage area; physical signs of tampered packaging or substituted contents; discreet interviews with colleagues who worked the same shifts.\n\nWhy: A pattern across independent evidence sources is far more reliable than any single signal.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Conduct the internal review",
          "why": "A pattern across independent evidence sources is far more reliable than any single signal."
        },
        {
          "detail": "Weigh the evidence gathered against the standard the practice's counsel or HR resource advised.",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "confirmed",
              "label": "Findings confirm diversion by a specific individual"
            },
            {
              "goto": "s16",
              "id": "inconclusive",
              "label": "Inconclusive — no individual can be confirmed"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Do the findings confirm diversion?"
        },
        {
          "detail": "The registrant dentist reviews the investigation findings and confirms them before any DEA/board reporting decision or termination proceeds.\n\nWhy: The registrant is personally accountable for the controlled-substance record the diversion touched, so they confirm the finding before it drives a personnel or regulatory action.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Registrant dentist reviews findings before reporting or termination.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "dentist",
          "title": "Registrant dentist reviews findings before reporting or termination",
          "why": "The registrant is personally accountable for the controlled-substance record the diversion touched, so they confirm the finding before it drives a personnel or regulatory action."
        },
        {
          "detail": "Following the HR/employment-law guidance obtained earlier, decide suspension or termination and document the decision and its basis.\n\nWhy: A generic HR functional equivalent — the practice follows its own employment-law process here, not a dental-specific rule.",
          "id": "s11",
          "kind": "step",
          "role": "hr",
          "title": "Decide and document the employment action",
          "why": "A generic HR functional equivalent — the practice follows its own employment-law process here, not a dental-specific rule."
        },
        {
          "detail": "File the required DEA report and any state dental board notification for confirmed staff diversion of controlled substances.\n\nWhy: Confirmed diversion is a reportable controlled-substance event separate from the employment action.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Report confirmed diversion to DEA and the state board",
          "why": "Confirmed diversion is a reportable controlled-substance event separate from the employment action."
        },
        {
          "detail": "Retain the evidence log, HR/counsel consultation notes, findings, employment action taken, and any regulatory report confirmations together for the required retention period.\n\nRecord: Evidence reviewed, findings, employment action, and regulatory report confirmation numbers.",
          "id": "s13",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the complete investigation record"
        },
        {
          "detail": "Diversion investigation closed",
          "id": "s14",
          "kind": "step",
          "role": "practice-owner",
          "title": "Diversion investigation closed"
        },
        {
          "detail": "Document the decision to handle this internally and the reasoning (low complexity, clear evidence, low legal exposure).\n\nWhy: Not every suspicion needs outside counsel, but the decision to skip it should be a documented choice, not a default.",
          "id": "s15",
          "kind": "step",
          "role": "hr",
          "title": "Proceed with internal review",
          "why": "Not every suspicion needs outside counsel, but the decision to skip it should be a documented choice, not a default."
        },
        {
          "detail": "Document what was reviewed and why it was inconclusive; restore normal access unless a documented reason remains to keep it restricted.\n\nRecord: Evidence reviewed, conclusion reached, and access-restoration decision.",
          "id": "s16",
          "kind": "step",
          "role": "hr",
          "title": "Close the review with no action"
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Suspected staff diversion of controlled substances or nitrous oxide — Unexplained discrepancies, tampered packaging, or behavioral signs in a team member.",
      "title": "Suspected staff diversion of controlled substances or nitrous oxide",
      "trigger": "Unexplained discrepancies, tampered packaging, or behavioral signs in a team member",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "source": "DEA regulations 21 CFR Parts 1301–1308 (registration, security, records, orders, disposal, prescriptions)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        },
        {
          "kind": "regulation",
          "label": "21 CFR 1301.52 — distribution/transfer of controlled substances upon discontinuance of a registrant's business",
          "source": "21 CFR 1301.52 — distribution/transfer of controlled substances upon discontinuance of a registrant's business",
          "url": "https://www.ecfr.gov/current/title-21/chapter-II"
        }
      ],
      "class": "pharmacology-prescribing",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "rx-019",
      "kind": "clinical",
      "materials": [
        "DEA registration certificate",
        "perpetual inventory log",
        "DEA online registration portal login",
        "incoming registrant's DEA number (if applicable)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Get the exact last date the departing dentist will be the registrant of record, and note whether an incoming dentist will take over prescribing at this location.\n\nWhy: The physical inventory and every downstream step have to be dated to this exact handover moment.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Confirm the departure date and scenario",
          "why": "The physical inventory and every downstream step have to be dated to this exact handover moment."
        },
        {
          "detail": "Count every controlled substance on hand and reconcile it against the perpetual inventory log, dated to the departure date.\n\nWhy: The outgoing registrant's accountability for the record has to close on a verified count, not an assumed one.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Take a full physical inventory as of the departure date",
          "why": "The outgoing registrant's accountability for the record has to close on a verified count, not an assumed one."
        },
        {
          "detail": "Compare the physical count to the running balance in the log.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "matches",
              "label": "Matches"
            },
            {
              "goto": "s11",
              "id": "mismatch",
              "label": "Discrepancy found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the physical count match the perpetual log?"
        },
        {
          "detail": "Determine whether another dentist will hold DEA registration for controlled-substance prescribing at this practice going forward.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "incoming-registrant",
              "label": "Incoming registrant will take over"
            },
            {
              "goto": "s12",
              "id": "no-incoming",
              "label": "No incoming registrant — practice will not hold controlled stock"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is there an incoming registrant at this location?"
        },
        {
          "detail": "Move the reconciled controlled stock and perpetual log under the incoming dentist's own DEA registration number, with a dated transfer record signed by both the outgoing and incoming registrants.\n\nWhy: Controlled stock is never simply left behind — custody has to move to a specific, currently valid registration.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Transfer stock and log to the new registrant",
          "why": "Controlled stock is never simply left behind — custody has to move to a specific, currently valid registration."
        },
        {
          "detail": "The departing (and, if applicable, the incoming) registrant reviews and signs the completed transfer or closure record before it is filed.\n\nWhy: The record closing out one registrant's accountability has to be confirmed by that registrant personally.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Departing registrant confirms the transfer or closure record.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Departing registrant confirms the transfer or closure record",
          "why": "The record closing out one registrant's accountability has to be confirmed by that registrant personally."
        },
        {
          "detail": "Submit the registration termination, or the confirmation tying stock to the new registrant's number, through the DEA online registration portal.\n\nWhy: The federal registration record has to reflect the change before the departing dentist's registration is treated as inactive at this location.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the registration change with DEA",
          "why": "The federal registration record has to reflect the change before the departing dentist's registration is treated as inactive at this location."
        },
        {
          "detail": "Remove the departing dentist's storage access (keys/codes), remove them from the perpetual log's list of authorized registrants, and update the compliance calendar with any new renewal dates for the incoming registrant.\n\nWhy: Access has to end at the same moment accountability ends, not sometime later.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Close out access and update the compliance calendar",
          "why": "Access has to end at the same moment accountability ends, not sometime later."
        },
        {
          "detail": "Retain the reconciled inventory, transfer or closure confirmation, DEA filing confirmation, and access-removal date together for the required retention period.\n\nRecord: Departure date, reconciled inventory, transfer/closure confirmation, DEA filing confirmation, access-removal date.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the complete handover record"
        },
        {
          "detail": "Prescriber separation handover complete",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Prescriber separation handover complete"
        },
        {
          "detail": "Route any unexplained shortage found at handover into rx-016 (theft or significant loss) and pause the transfer until that is resolved.\n\nWhy: A separation is not the time to quietly write off a discrepancy — it gets the same accountability process as any other mismatch.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escalate to the theft-or-loss protocol before continuing",
          "why": "A separation is not the time to quietly write off a discrepancy — it gets the same accountability process as any other mismatch."
        },
        {
          "detail": "If no incoming registrant will hold controlled stock at this location, transfer the reconciled stock to a DEA-registered reverse distributor and prepare to surrender the departing registration.\n\nWhy: A registration cannot sit open with no accountable registrant at the location.",
          "id": "s12",
          "kind": "step",
          "role": "practice-owner",
          "title": "Transfer remaining stock to a reverse distributor and prepare to close the registration",
          "why": "A registration cannot sit open with no accountable registrant at the location."
        }
      ],
      "subclass": "pharmacology-prescribing-and-controlled-substances",
      "summary": "Prescriber leaves the practice — DEA stock transfer, log close-out and registration update — A registrant dentist retires, sells or leaves.",
      "title": "Prescriber leaves the practice — DEA stock transfer, log close-out and registration update",
      "trigger": "A registrant dentist retires, sells or leaves",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 90,
      "frequency": "quarterly",
      "id": "sch-001",
      "kind": "operational",
      "materials": [
        "practice management system schedule editor",
        "provider hours/PTO calendar",
        "prior 90 days' production report by column",
        "block-type definitions"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "office-manager",
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Export column-by-column production totals, no-show/cancellation rate, and hours actually filled for each provider from the practice management system.\n\nWhy: The template is redesigned from what actually happened in the schedule, not from guesswork.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull production and utilization data for the last 90 days",
          "why": "The template is redesigned from what actually happened in the schedule, not from guesswork."
        },
        {
          "detail": "Check each provider's contracted days/hours, planned PTO, and any hire or hours change effective in the template period.\n\nWhy: A template built on stale hours creates phantom open slots or double-books a provider who is actually out.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm current provider hours and any upcoming changes",
          "why": "A template built on stale hours creates phantom open slots or double-books a provider who is actually out."
        },
        {
          "detail": "List the block types the column will use: new-patient exam, hygiene recall, doctor treatment (by time-unit length), emergency/buffer, and admin/lunch. Assign each a default length.\n\nWhy: Blocks group similar-length procedures so gaps are minimized and emergency capacity is protected.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Define or confirm block types for each column",
          "why": "Blocks group similar-length procedures so gaps are minimized and emergency capacity is protected."
        },
        {
          "detail": "Reserve at least one short same-day slot per provider per day (see sch-013 same-day emergency protocol) rather than filling every column solid.\n\nWhy: Without a reserved slot, a same-day emergency forces a bump or an unpaid overtime add-on.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Place emergency/buffer slots across the week",
          "why": "Without a reserved slot, a same-day emergency forces a bump or an unpaid overtime add-on."
        },
        {
          "detail": "Ask the hygiene team whether the draft block lengths and buffer placement actually match real chair time for recall, perio and new-patient cleanings before the draft goes to doctor sign-off.\n\nWhy: The template directly sets hygiene-column length and utilization, so hygiene feedback belongs in the draft before it is locked, not after.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Collect hygiene-column feedback on block length and utilization",
          "why": "The template directly sets hygiene-column length and utilization, so hygiene feedback belongs in the draft before it is locked, not after."
        },
        {
          "detail": "Does the doctor sign off on the draft template?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "approve",
              "label": "Approve as drafted"
            },
            {
              "goto": "s3",
              "id": "revise",
              "label": "Request changes to block placement or length"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the doctor sign off on the draft template?"
        },
        {
          "detail": "Load the approved block layout as the standing template effective the agreed start date; lock past the go-live date to avoid accidental overwrite of live bookings.\n\nWhy: A published, dated template is the single source of truth the whole front desk books against.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Publish the template into the practice management system",
          "why": "A published, dated template is the single source of truth the whole front desk books against."
        },
        {
          "detail": "Record the effective date, what changed from the prior version, and the data that drove the change in the practice's operations log.\n\nRecord: template version, effective date, change rationale, approver",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the template version and rationale"
        },
        {
          "detail": "Walk the team through any changed block lengths, new buffer placement, or column reassignments before the effective date.\n\nWhy: A template the booking staff doesn't understand gets worked around, which defeats its purpose.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Brief the front desk and hygiene team on the new template",
          "why": "A template the booking staff doesn't understand gets worked around, which defeats its purpose."
        },
        {
          "detail": "Template live and team briefed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Template live and team briefed"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Build and maintain the schedule template (block scheduling) — A new provider starts, hours change, or the quarterly template review comes due.",
      "title": "Build and maintain the schedule template (block scheduling)",
      "trigger": "A new provider starts, hours change, or the quarterly template review comes due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 12,
      "frequency": "per-patient",
      "id": "sch-002",
      "kind": "operational",
      "materials": [
        "practice management system",
        "new-patient intake form link",
        "insurance verification checklist",
        "confirmation/reminder templates"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Ask the reason for scheduling (exam/cleaning, specific concern, pain) and whether there is any urgency to note for triage.\n\nWhy: The reason determines which block type and how soon the appointment needs to happen.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Greet the caller and capture the reason for the visit",
          "why": "The reason determines which block type and how soon the appointment needs to happen."
        },
        {
          "detail": "Does the caller describe an urgent or emergency symptom?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "routine",
              "label": "Routine exam/cleaning or non-urgent concern"
            },
            {
              "goto": "s9",
              "id": "urgent",
              "label": "Pain, swelling, trauma or other urgent symptom"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the caller describe an urgent or emergency symptom?"
        },
        {
          "detail": "Record name, date of birth, contact information, and insurance carrier/member details per the intake checklist.\n\nRecord: new patient demographic and insurance record created in the practice management system",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Collect demographics and insurance information"
        },
        {
          "detail": "Offer available new-patient exam blocks per the standing template (sch-001); confirm the patient's preferred day/time window.\n\nWhy: New-patient exams need the longer block length reserved in the template, not a routine recall slot.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Select an appointment slot matching the new-patient block",
          "why": "New-patient exams need the longer block length reserved in the template, not a routine recall slot."
        },
        {
          "detail": "Send the new-patient intake form electronically and tell the patient the arrive-by time, parking/entrance notes, and what to bring (insurance card, ID, medication list).\n\nWhy: Forms completed before arrival keep the exam block on schedule instead of eating chair time on paperwork.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the intake form link and arrival instructions",
          "why": "Forms completed before arrival keep the exam block on schedule instead of eating chair time on paperwork."
        },
        {
          "detail": "Confirm the patient's preferred contact channel(s) and consent to automated text/call reminders (TCPA 47 U.S.C. §227), then enroll in the 7-day/2-day/day-of cascade (sch-007).\n\nWhy: New patients have the highest no-show risk of any visit type, so the confirmation cascade matters most here.",
          "id": "s6",
          "kind": "step",
          "role": "scheduler",
          "title": "Enroll the appointment in the confirmation cascade",
          "why": "New patients have the highest no-show risk of any visit type, so the confirmation cascade matters most here."
        },
        {
          "detail": "Confirm the appointment record shows date/time, block type, referral source, and confirmation consent on file.\n\nRecord: appointment record with block type, source, and confirmation consent",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Document the booking"
        },
        {
          "detail": "New patient appointment booked and enrolled in confirmations",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "New patient appointment booked and enrolled in confirmations"
        },
        {
          "detail": "Do not book a routine slot for an urgent symptom — hand off to the same-day emergency patient slot protocol (sch-013) instead.\n\nWhy: Booking urgent symptoms into a routine future slot delays care and often produces a same-day cancellation and re-book anyway.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Route to the same-day emergency slot protocol",
          "why": "Booking urgent symptoms into a routine future slot delays care and often produces a same-day cancellation and re-book anyway."
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Booking a new patient appointment — A new patient agrees to schedule — demographics, insurance, chief concern, forms sent, arrival instructions given.",
      "title": "Booking a new patient appointment",
      "trigger": "A new patient agrees to schedule — demographics, insurance, chief concern, forms sent, arrival instructions given",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "sch-003",
      "kind": "operational",
      "materials": [
        "accepted treatment plan with procedure codes and time units",
        "practice management system",
        "provider column availability",
        "lab case timeline if applicable"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Get the procedure code(s), required time units, provider, and any sequencing requirements (e.g. phase 2 must follow phase 1 by a minimum interval) from the treatment coordinator.\n\nWhy: Booking off an informal verbal description risks the wrong block length or the wrong order of phases.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Receive the accepted treatment plan handoff",
          "why": "Booking off an informal verbal description risks the wrong block length or the wrong order of phases."
        },
        {
          "detail": "Does this procedure depend on a lab case (crown, denture, appliance)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-lab",
              "label": "No lab case involved"
            },
            {
              "goto": "s9",
              "id": "lab-case",
              "label": "Lab case required before this visit can be scheduled"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "scheduler",
          "title": "Does this procedure depend on a lab case (crown, denture, appliance)?"
        },
        {
          "detail": "Use the practice's time-unit-to-minutes conversion to reserve the correct column length, including any assistant or sterilization turnaround time.\n\nWhy: Undersizing the block cascades delays through the rest of the day's column.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Convert treatment plan time units into a schedule block",
          "why": "Undersizing the block cascades delays through the rest of the day's column."
        },
        {
          "detail": "Offer the earliest dates matching the required block and provider; confirm the patient's choice and any pre-visit instructions (e.g. pre-medication, fasting for sedation).\n\nWhy: Some treatment types carry pre-visit instructions that must be given with enough lead time to follow.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Offer available dates and confirm with the patient",
          "why": "Some treatment types carry pre-visit instructions that must be given with enough lead time to follow."
        },
        {
          "detail": "Verify the accepted plan's financial arrangement (insurance estimate, payment plan, or deposit) is recorded before the appointment is locked in.\n\nWhy: Booking a treatment visit with no financial arrangement on file is a common source of same-day billing disputes.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Confirm the financial arrangement is on file before finalizing",
          "why": "Booking a treatment visit with no financial arrangement on file is a common source of same-day billing disputes."
        },
        {
          "detail": "Enroll the visit in the 7-day/2-day/day-of confirmation cascade (sch-007) with any procedure-specific pre-visit reminder attached.\n\nWhy: Treatment visits are costlier to lose to a no-show than routine recall, so confirmation matters more here.",
          "id": "s6",
          "kind": "step",
          "role": "scheduler",
          "title": "Enroll the appointment in the confirmation cascade",
          "why": "Treatment visits are costlier to lose to a no-show than routine recall, so confirmation matters more here."
        },
        {
          "detail": "Confirm the appointment record links to the treatment plan phase, procedure code, and financial arrangement reference.\n\nRecord: appointment linked to treatment plan phase and financial arrangement",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Document the booked treatment appointment"
        },
        {
          "detail": "Treatment appointment booked and linked to the accepted plan",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Treatment appointment booked and linked to the accepted plan"
        },
        {
          "detail": "Check the lab liaison's expected case-back date and build in a buffer before offering the appointment date to the patient.\n\nWhy: Booking before the lab case is confirmed back risks a same-day reschedule if the case is late.",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Confirm the lab case turnaround before setting a date",
          "why": "Booking before the lab case is confirmed back risks a same-day reschedule if the case is late."
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Booking doctor treatment from an accepted treatment plan — The treatment coordinator hands off an accepted plan with procedure, time units and sequencing.",
      "title": "Booking doctor treatment from an accepted treatment plan",
      "trigger": "The treatment coordinator hands off an accepted plan with procedure, time units and sequencing",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 4,
      "frequency": "per-patient",
      "id": "sch-004",
      "kind": "operational",
      "materials": [
        "hygienist recall interval note",
        "practice management system",
        "recall reminder-eligibility flag"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Hand off the recommended interval (e.g. 3, 4 or 6 months) and any follow-up note (e.g. perio re-eval) to the front desk before checkout.\n\nWhy: The front desk cannot pre-appoint correctly without knowing the clinically recommended interval.",
          "id": "s1",
          "kind": "step",
          "role": "hygienist",
          "title": "Note the recommended recall interval before the patient leaves the operatory",
          "why": "The front desk cannot pre-appoint correctly without knowing the clinically recommended interval."
        },
        {
          "detail": "Offer a concrete date/time matching the recall interval rather than asking an open-ended \"call us later\" question.\n\nWhy: A specific offer converts to a booked visit far more often than an open-ended one, and locks in schedule fill months ahead.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer a specific date and time at the checkout desk",
          "why": "A specific offer converts to a booked visit far more often than an open-ended one, and locks in schedule fill months ahead."
        },
        {
          "detail": "Does the patient accept the offered slot?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "accept",
              "label": "Patient accepts and books now"
            },
            {
              "goto": "s7",
              "id": "decline",
              "label": "Patient wants to be contacted closer to the due date instead"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient accept the offered slot?"
        },
        {
          "detail": "Enroll the newly booked future recall visit in the standard 7-day/2-day/day-of confirmation cascade (sch-007).\n\nWhy: A visit booked months out is the most likely to be forgotten without confirmations closer to the date.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Enroll the pre-appointed visit in the confirmation cascade",
          "why": "A visit booked months out is the most likely to be forgotten without confirmations closer to the date."
        },
        {
          "detail": "Record whether the patient pre-appointed or was flagged for recall outreach instead.\n\nRecord: pre-appointment outcome: booked with date, or flagged for recall outreach",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the pre-appointment outcome"
        },
        {
          "detail": "Checkout complete with next hygiene visit booked or flagged",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Checkout complete with next hygiene visit booked or flagged"
        },
        {
          "detail": "Mark the patient's chart for recall outreach ahead of the due date instead of a booked appointment.\n\nWhy: A flagged-not-booked patient still needs active outreach or the recall interval slips silently.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the patient for the recall reminder queue",
          "why": "A flagged-not-booked patient still needs active outreach or the recall interval slips silently."
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Pre-appointing the next hygiene visit at checkout — Every hygiene checkout before the patient leaves the desk.",
      "title": "Pre-appointing the next hygiene visit at checkout",
      "trigger": "Every hygiene checkout before the patient leaves the desk",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "sch-005",
      "kind": "operational",
      "materials": [
        "practice management system",
        "family/guarantor account records",
        "column and chair availability by time slot"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Get each family member's name and visit type (exam, cleaning, treatment) rather than assuming everyone needs the same thing.\n\nWhy: Mixed needs (one cleaning, one treatment) require different block lengths and possibly different providers.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "List each family member and what each one needs",
          "why": "Mixed needs (one cleaning, one treatment) require different block lengths and possibly different providers."
        },
        {
          "detail": "Confirm enough chairs/columns are open at the same or overlapping time to seat every family member without one waiting excessively.\n\nWhy: Committing to a family block the practice cannot actually staff creates a bad first impression and cascades delays.",
          "id": "s2",
          "kind": "step",
          "role": "scheduler",
          "title": "Check chair and provider capacity for a shared time window",
          "why": "Committing to a family block the practice cannot actually staff creates a bad first impression and cascades delays."
        },
        {
          "detail": "Can every family member be seated at the same or a tightly overlapping time?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes-full",
              "label": "Yes — full family block available"
            },
            {
              "goto": "s8",
              "id": "partial",
              "label": "Only some members fit; others need a different day/time"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "scheduler",
          "title": "Can every family member be seated at the same or a tightly overlapping time?"
        },
        {
          "detail": "Enter each appointment individually but tag them as a linked family block in the practice management system so the front desk can seat the family together.\n\nWhy: Linking the records lets check-in staff seat the family as a unit instead of treating them as unrelated walk-ins.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Book each family member's appointment, linked under the same visit window",
          "why": "Linking the records lets check-in staff seat the family as a unit instead of treating them as unrelated walk-ins."
        },
        {
          "detail": "Enroll each family member's appointment in the standard confirmation cascade (sch-007), directed to the caregiver's contact preference.\n\nWhy: One missed confirmation in a family block can cause the whole group to no-show.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Enroll each linked appointment in the confirmation cascade",
          "why": "One missed confirmation in a family block can cause the whole group to no-show."
        },
        {
          "detail": "Record which family members were booked together, which (if any) were split to a different time, and the guarantor/caregiver contact used.\n\nRecord: linked family block with member list and any split appointments",
          "id": "s6",
          "kind": "step",
          "role": "scheduler",
          "title": "Document the family block"
        },
        {
          "detail": "Family members booked and linked as a block",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Family members booked and linked as a block"
        },
        {
          "detail": "Book the members that fit together now and offer the earliest available separate slot(s) for the remainder, explaining the reason to the caregiver.\n\nWhy: Being upfront about a partial fit avoids a caregiver assuming everyone is booked when they are not.",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Offer a partial block plus separate slots for the rest",
          "why": "Being upfront about a partial fit avoids a caregiver assuming everyone is booked when they are not."
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Family block and multi-patient booking — A caregiver asks to book several family members together.",
      "title": "Family block and multi-patient booking",
      "trigger": "A caregiver asks to book several family members together",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 8,
      "frequency": "as-needed",
      "id": "sch-006",
      "kind": "operational",
      "materials": [
        "practice's overlap/double-booking policy",
        "practice management system",
        "assistant/hygiene-aide staffing schedule"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Determine whether the overlap is to work in a short procedure alongside a longer hygiene visit, fit an emergency, or a scheduling error being corrected.\n\nWhy: The reason determines which overlap rule applies and whether it should be approved at all.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Identify why an overlap is being considered",
          "why": "The reason determines which overlap rule applies and whether it should be approved at all."
        },
        {
          "detail": "Check that an assistant or hygiene aide is actually available to run the second chair for the overlapping period — an overlap with no one to staff it is not a real overlap, it is a delay.\n\nWhy: The practice's capacity is staffing-limited, not just chair-limited; an unstaffed overlap just pushes the wait onto the patient.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm staffing supports the overlap",
          "why": "The practice's capacity is staffing-limited, not just chair-limited; an unstaffed overlap just pushes the wait onto the patient."
        },
        {
          "detail": "Is the procedure type eligible for overlap under the practice's policy?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "eligible",
              "label": "Eligible short procedure or provider check-in during assisted hygiene"
            },
            {
              "goto": "s7",
              "id": "not-eligible",
              "label": "Not eligible (e.g. two full-length treatment visits requiring the doctor's full attention)"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the procedure type eligible for overlap under the practice's policy?"
        },
        {
          "detail": "Enter both appointments with the assigned assistant/hygienist noted so the front desk knows who runs each chair.\n\nWhy: An overlap without a clearly assigned staff member for each chair leads to a patient sitting unattended.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Book the overlap with the staffing assignment noted",
          "why": "An overlap without a clearly assigned staff member for each chair leads to a patient sitting unattended."
        },
        {
          "detail": "Record whether the overlap was approved or declined, the reason, and the staffing assignment if approved.\n\nRecord: overlap decision with reason and staffing assignment",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the overlap decision"
        },
        {
          "detail": "Overlap request resolved",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Overlap request resolved"
        },
        {
          "detail": "Tell the patient or caller the requested time is not available and offer the next open non-overlapping slot instead.\n\nWhy: Declining protects both patients' time and the provider from being spread across two chairs beyond what is safe or reasonable.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Decline the overlap and offer the next available separate slot",
          "why": "Declining protects both patients' time and the provider from being spread across two chairs beyond what is safe or reasonable."
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Double-booking and assisted-hygiene overlap rules — The scheduler considers overlapping two appointments in one column.",
      "title": "Double-booking and assisted-hygiene overlap rules",
      "trigger": "The scheduler considers overlapping two appointments in one column",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "sch-007",
      "kind": "operational",
      "materials": [
        "automated text/email/voice reminder system",
        "TCPA consent on file",
        "practice management system appointment status field",
        "manual call list for unconfirmed appointments"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the patient consented to automated text/call reminders per TCPA 47 U.S.C. §227 before enrolling the appointment in the automated cascade; if no consent is on file, use manual outreach only.\n\nWhy: Sending automated reminders without consent on file is a compliance exposure, not just a courtesy issue.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Verify TCPA consent is on file for automated contact",
          "why": "Sending automated reminders without consent on file is a compliance exposure, not just a courtesy issue."
        },
        {
          "detail": "Send the automated reminder at 7 days out via the patient's preferred channel, including a clear confirm/reschedule action. Any AI-drafted reminder copy is reviewed by front-office staff before it is sent; this reminder is administrative scheduling information, not clinical guidance, so AB 3030's patient-facing clinical-communication disclosure does not apply here.\n\nWhy: Confirming a week out gives enough runway to fill the slot from the short-call list if the patient cancels.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the 7-day reminder",
          "why": "Confirming a week out gives enough runway to fill the slot from the short-call list if the patient cancels."
        },
        {
          "detail": "Did the patient confirm at the 7-day touch?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "confirmed",
              "label": "Confirmed"
            },
            {
              "goto": "s4",
              "id": "no-response",
              "label": "No response yet"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the patient confirm at the 7-day touch?"
        },
        {
          "detail": "Send the automated reminder at 2 days out regardless of the 7-day response, unless the appointment status already shows confirmed and the patient opted out of repeat reminders.\n\nWhy: A second touch closer to the date catches patients who ignored the first reminder or whose plans changed.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the 2-day reminder",
          "why": "A second touch closer to the date catches patients who ignored the first reminder or whose plans changed."
        },
        {
          "detail": "Did the patient confirm at the 2-day touch?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "confirmed",
              "label": "Confirmed"
            },
            {
              "goto": "s6",
              "id": "still-no-response",
              "label": "Still no response"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the patient confirm at the 2-day touch?"
        },
        {
          "detail": "Send a final same-day reminder with the specific arrival time and location.\n\nWhy: A day-of touch catches last-minute confusion about the time even for patients who already confirmed.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the day-of reminder",
          "why": "A day-of touch catches last-minute confusion about the time even for patients who already confirmed."
        },
        {
          "detail": "Is the appointment confirmed by 24 hours before the visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "confirmed-final",
              "label": "Confirmed"
            },
            {
              "goto": "s10",
              "id": "unconfirmed-final",
              "label": "Still unconfirmed at 24 hours"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "scheduler",
          "title": "Is the appointment confirmed by 24 hours before the visit?"
        },
        {
          "detail": "Record which touch(es) produced confirmation and update the appointment status field.\n\nRecord: confirmation status and which cascade touch produced it",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Document the confirmation status"
        },
        {
          "detail": "Confirmation cascade complete for this appointment",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Confirmation cascade complete for this appointment"
        },
        {
          "detail": "Hand off to the dedicated unconfirmed-at-24-hours protocol (sch-008) for manual phone outreach and short-call list preparation.\n\nWhy: An exhausted automated cascade with no confirmation needs a human call, not another automated message.",
          "id": "s10",
          "kind": "step",
          "role": "scheduler",
          "title": "Route to the unconfirmed-at-24-hours protocol",
          "why": "An exhausted automated cascade with no confirmation needs a human call, not another automated message."
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Appointment confirmation cascade (7-day, 2-day, day-of) — Automated per appointment; manual outreach for anything still unconfirmed at 24 hours.",
      "title": "Appointment confirmation cascade (7-day, 2-day, day-of)",
      "trigger": "Automated per appointment; manual outreach for anything still unconfirmed at 24 hours",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "sch-008",
      "kind": "operational",
      "materials": [
        "practice management system",
        "short-call/ASAP list",
        "manual call script",
        "broken-appointment policy reference"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Call the patient directly using the number on file; if no answer, leave a voicemail asking them to confirm or reschedule and follow with a text if consent is on file.\n\nWhy: A human call reaches patients who ignore automated texts and gives a chance to catch a genuine scheduling conflict before it becomes a no-show.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Place a manual phone call to the patient",
          "why": "A human call reaches patients who ignore automated texts and gives a chance to catch a genuine scheduling conflict before it becomes a no-show."
        },
        {
          "detail": "Was the patient reached (by call, callback, or reply)?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "reached-confirms",
              "label": "Reached and confirms attendance"
            },
            {
              "goto": "s5",
              "id": "reached-cancels",
              "label": "Reached and wants to cancel or reschedule"
            },
            {
              "goto": "s6",
              "id": "not-reached",
              "label": "Not reached after the attempt window"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "scheduler",
          "title": "Was the patient reached (by call, callback, or reply)?"
        },
        {
          "detail": "Update the appointment status to confirmed and note it required manual outreach.\n\nRecord: confirmation status updated with manual-outreach note",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Document the confirmation reached by manual call"
        },
        {
          "detail": "Unconfirmed appointment resolved",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Unconfirmed appointment resolved"
        },
        {
          "detail": "If the reschedule request comes in under 24 hours of the appointment, hand off to the same-day cancellation protocol (sch-009); otherwise rebook directly.\n\nWhy: A cancellation this close to the appointment needs the same-day cancellation handling to try to refill the slot in time.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Route to the same-day cancellation protocol if applicable",
          "why": "A cancellation this close to the appointment needs the same-day cancellation handling to try to refill the slot in time."
        },
        {
          "detail": "Hold the slot a little longer or release it to the short-call list?",
          "forks": [
            {
              "goto": "s8",
              "id": "hold",
              "label": "Hold — appointment history suggests this patient reliably shows even without confirming"
            },
            {
              "advised": true,
              "goto": "s7",
              "id": "release",
              "label": "Release to the short-call list to protect the slot"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "scheduler",
          "title": "Hold the slot a little longer or release it to the short-call list?"
        },
        {
          "detail": "Mark the slot as at-risk and offer it to the top of the short-call list per the quick-fill protocol (sch-011), while keeping the original patient's appointment intact unless and until it is actually filled.\n\nWhy: Working the short-call list in parallel protects production if the unconfirmed patient does turn out to no-show.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Release the slot to the short-call/ASAP list",
          "why": "Working the short-call list in parallel protects production if the unconfirmed patient does turn out to no-show."
        },
        {
          "detail": "Record whether the slot was held as-is or released to the short-call list, and why.\n\nRecord: hold/release decision and reasoning",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Document the hold/release decision"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Patient still unconfirmed 24 hours out — The confirmation cascade is exhausted with no reply the day before the appointment.",
      "title": "Patient still unconfirmed 24 hours out",
      "trigger": "The confirmation cascade is exhausted with no reply the day before the appointment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "sch-009",
      "kind": "operational",
      "materials": [
        "schedule template with confirmation status",
        "short-call / ASAP list",
        "broken-appointment policy",
        "patient chart note field"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the patient's name and appointment time, ask briefly why they are cancelling, and thank them for calling instead of no-showing.\n\nWhy: A same-day call, even a cancellation, is easier to work with than a silent no-show and keeps the relationship positive.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Take the cancellation and note the reason",
          "why": "A same-day call, even a cancellation, is easier to work with than a silent no-show and keeps the relationship positive."
        },
        {
          "detail": "Is the reason an emergency or medical issue needing triage?\n\nWhy: A patient cancelling due to their own new symptoms may need emergency triage routed separately, not just a rebooking.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "routine",
              "label": "Routine reason (conflict, transportation, forgot)"
            },
            {
              "goto": "s9",
              "id": "symptom-reason",
              "label": "Patient describes new pain, swelling or a medical concern"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the reason an emergency or medical issue needing triage?",
          "why": "A patient cancelling due to their own new symptoms may need emergency triage routed separately, not just a rebooking."
        },
        {
          "detail": "Change the appointment status to cancelled (not deleted) so the opening and the history both remain visible.\n\nRecord: Cancellation timestamp, reason category, and staff initials on the appointment.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Mark the appointment cancelled in the schedule"
        },
        {
          "detail": "Does this patient already have a recent broken-appointment history?\n\nWhy: A repeat pattern needs the escalation protocol, not just a routine rebooking offer.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "first-or-rare",
              "label": "First or infrequent cancellation in the last 12 months"
            },
            {
              "goto": "s10",
              "id": "repeat",
              "label": "Second or third broken appointment in 12 months"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "scheduler",
          "title": "Does this patient already have a recent broken-appointment history?",
          "why": "A repeat pattern needs the escalation protocol, not just a routine rebooking offer."
        },
        {
          "detail": "Offer the next available opening, or add the patient to the short-call/ASAP list if they cannot commit to a new time today.\n\nWhy: Rebooking on the same call captures the patient before they forget or lose motivation.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer to rebook before ending the call",
          "why": "Rebooking on the same call captures the patient before they forget or lose motivation."
        },
        {
          "detail": "Is the newly opened slot fillable before the day starts?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "fillable",
              "label": "Enough lead time to work the short-call list"
            },
            {
              "goto": "s11",
              "id": "too-late",
              "label": "Too close to the appointment time to realistically fill"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "scheduler",
          "title": "Is the newly opened slot fillable before the day starts?"
        },
        {
          "detail": "Pass the opened slot to the quick-fill-from-short-call-list protocol to work the ASAP list.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Hand the opening to the short-call fill protocol"
        },
        {
          "detail": "Same-day cancellation handled",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Same-day cancellation handled"
        },
        {
          "detail": "Route the caller to the same-day emergency patient slot protocol so the concern is triaged rather than only rebooked.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to same-day emergency intake"
        },
        {
          "detail": "Add a flag to the patient's chart and hand the case to the office manager to run the repeat broken-appointment escalation protocol.",
          "id": "s10",
          "kind": "step",
          "role": "scheduler",
          "title": "Flag the chart for the broken-appointment escalation protocol"
        },
        {
          "detail": "Leave the slot flagged as open so it surfaces in the afternoon schedule audit for tomorrow-prep or same-day emergency use.\n\nRecord: Open slot noted with time and reason on the day's schedule.",
          "id": "s11",
          "kind": "step",
          "role": "scheduler",
          "title": "Note the unfilled opening for the daily schedule audit"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Same-day cancellation received — A patient cancels with less than 24 hours' notice.",
      "title": "Same-day cancellation received",
      "trigger": "A patient cancels with less than 24 hours' notice",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "sch-010",
      "kind": "operational",
      "materials": [
        "schedule with appointment status",
        "patient contact information on file",
        "no-show policy",
        "short-call list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "front-desk",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the clock against the scheduled time and confirm no call, text or arrival has been logged.\n\nWhy: A firm threshold avoids marking patients no-show for normal traffic delay while still catching real no-shows early enough to refill the slot.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm ten minutes have passed with no patient and no contact",
          "why": "A firm threshold avoids marking patients no-show for normal traffic delay while still catching real no-shows early enough to refill the slot."
        },
        {
          "detail": "Call the primary number on file; if no answer, send a text asking if they are on their way or need to reschedule.\n\nWhy: Some 'no-shows' are simply running late or had a scheduling mix-up that a quick call resolves.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Attempt to reach the patient",
          "why": "Some 'no-shows' are simply running late or had a scheduling mix-up that a quick call resolves."
        },
        {
          "detail": "Did the patient respond?",
          "forks": [
            {
              "goto": "s9",
              "id": "en-route",
              "label": "Patient is en route or on the phone now"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "no-response",
              "label": "No response within a reasonable window"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Did the patient respond?"
        },
        {
          "detail": "Change the appointment status to no-show (not cancelled) so the pattern is tracked separately from cancellations.\n\nRecord: No-show timestamp, contact attempts made, and staff initials on the appointment.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Mark the appointment no-show in the schedule"
        },
        {
          "detail": "Is this a first no-show or a repeat within 12 months?\n\nWhy: Repeat no-shows need the formal escalation and possible policy consequence; a first no-show gets a courtesy note.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "first",
              "label": "First no-show in 12 months"
            },
            {
              "goto": "s10",
              "id": "repeat",
              "label": "Second or third no-show in 12 months"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "scheduler",
          "title": "Is this a first no-show or a repeat within 12 months?",
          "why": "Repeat no-shows need the formal escalation and possible policy consequence; a first no-show gets a courtesy note."
        },
        {
          "detail": "Note the no-show in the chart without a fee or warning; flag it so the next outreach offers rebooking.\n\nRecord: Chart note: first no-show, no action taken, rebooking flag set.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Add a courtesy chart note and offer rebooking on next contact"
        },
        {
          "detail": "Pass the opened slot to the quick-fill-from-short-call-list protocol so the chair time is not wasted.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Hand the newly open slot to the short-call fill protocol"
        },
        {
          "detail": "No-show handled",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "No-show handled"
        },
        {
          "detail": "If the patient confirms they are coming, route the case to the late-arrival decision protocol to decide see/shorten/reschedule.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to the late-arrival decision protocol"
        },
        {
          "detail": "Pass the chart to the office manager to apply the repeat broken-appointment policy escalation protocol (fee, deposit or waitlist-only booking).",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the broken-appointment escalation protocol"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "No-show at ten minutes past: contact, rebook and policy note — Ten minutes past the appointment time with no contact from the patient.",
      "title": "No-show at ten minutes past: contact, rebook and policy note",
      "trigger": "Ten minutes past the appointment time with no contact from the patient",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "sch-011",
      "kind": "operational",
      "materials": [
        "short-call / ASAP list with patient preferences",
        "schedule template",
        "text/call outreach channel"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note the exact start time, duration, chair/operatory and what type of appointment fits (hygiene, doctor treatment, etc.).\n\nWhy: Matching the opening's requirements first avoids offering it to a patient whose needed procedure does not fit the slot.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Identify the opening's time, length and procedure need",
          "why": "Matching the opening's requirements first avoids offering it to a patient whose needed procedure does not fit the slot."
        },
        {
          "detail": "Does the short-call list have a matching patient?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "match-found",
              "label": "One or more patients on the list match the opening"
            },
            {
              "goto": "s7",
              "id": "no-match",
              "label": "No matching patient on the list"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "scheduler",
          "title": "Does the short-call list have a matching patient?"
        },
        {
          "detail": "Call or text the patient offering the specific date and time; ask for a response within a set window (e.g. 30 minutes).\n\nWhy: A time-boxed offer keeps the opening from sitting idle while one patient decides.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Contact the highest-priority matching patient",
          "why": "A time-boxed offer keeps the opening from sitting idle while one patient decides."
        },
        {
          "detail": "Did the patient accept within the response window?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accepted",
              "label": "Patient accepts the slot"
            },
            {
              "goto": "s8",
              "id": "declined-or-no-reply",
              "label": "Patient declines or does not reply in time"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "scheduler",
          "title": "Did the patient accept within the response window?"
        },
        {
          "detail": "Schedule the patient into the opening and remove or update their short-call list entry so they are not double-offered.\n\nRecord: Appointment booked; short-call list entry closed with fill date noted.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Book the appointment and remove the patient from the short-call list"
        },
        {
          "detail": "Short-call fill attempt complete",
          "id": "s6",
          "kind": "step",
          "role": "scheduler",
          "title": "Short-call fill attempt complete"
        },
        {
          "detail": "Mark the opening as attempted-unfilled with the number of patients contacted, so it surfaces in the schedule audit.\n\nRecord: Unfilled opening logged with outreach attempts and time.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Log the opening as unfilled for the daily audit"
        },
        {
          "detail": "Is there another matching patient on the list?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes-next",
              "label": "Another match available"
            },
            {
              "goto": "s7",
              "id": "list-exhausted",
              "label": "No more matches on the list"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "scheduler",
          "title": "Is there another matching patient on the list?"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Filling an opening from the short-call / ASAP list — An opening appears in today's or tomorrow's schedule.",
      "title": "Filling an opening from the short-call / ASAP list",
      "trigger": "An opening appears in today's or tomorrow's schedule",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "sch-012",
      "kind": "operational",
      "materials": [
        "broken-appointment policy document",
        "patient chart with broken-appointment history",
        "fee schedule or deposit policy if used"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Pull the patient's cancellation and no-show history for the trailing 12 months and confirm this is genuinely the second or third instance.\n\nWhy: Escalating on a miscount damages the relationship and undermines trust in the policy.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the broken-appointment count from the chart history",
          "why": "Escalating on a miscount damages the relationship and undermines trust in the policy."
        },
        {
          "detail": "What consequence tier applies?\n\nWhy: A graduated policy (warning, then deposit, then waitlist-only) is fairer and more defensible than jumping straight to dismissal.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "warning",
              "label": "Second instance: formal warning note and verbal notice"
            },
            {
              "goto": "s3",
              "id": "deposit",
              "label": "Third instance: require a deposit or pre-payment to book ahead"
            },
            {
              "goto": "s3",
              "id": "waitlist-only",
              "label": "Pattern continues after deposit: waitlist-only, no advance booking"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "What consequence tier applies?",
          "why": "A graduated policy (warning, then deposit, then waitlist-only) is fairer and more defensible than jumping straight to dismissal."
        },
        {
          "detail": "The office manager reviews and signs off on the consequence tier before it is applied or communicated to the patient — this affects money owed and future access to booking, so it is not a front-desk-only call.\n\nWhy: Financial and access consequences on a patient account should have management sign-off, not a single staff member's unilateral decision.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager sign-off before applying the consequence.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager sign-off before applying the consequence",
          "why": "Financial and access consequences on a patient account should have management sign-off, not a single staff member's unilateral decision."
        },
        {
          "detail": "Call or send a written notice explaining the broken-appointment count, the policy, and what is required to book their next visit.\n\nWhy: Patients should hear the policy directly rather than discover it only when they try to book and are refused.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the patient of the policy and the consequence",
          "why": "Patients should hear the policy directly rather than discover it only when they try to book and are refused."
        },
        {
          "detail": "Does this patient's clinical relationship need the dentist's input (e.g. possible dismissal from the practice)?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-dismissal",
              "label": "Policy consequence only, relationship continues"
            },
            {
              "goto": "s8",
              "id": "dismissal-consideration",
              "label": "Pattern is severe enough to consider ending the treatment relationship"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does this patient's clinical relationship need the dentist's input (e.g. possible dismissal from the practice)?"
        },
        {
          "detail": "Note the pattern, the consequence applied, who approved it, and the date the patient was notified.\n\nRecord: Escalation note: broken-appointment count, tier applied, approver, notification date.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the escalation and consequence in the chart"
        },
        {
          "detail": "Broken-appointment escalation complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Broken-appointment escalation complete"
        },
        {
          "detail": "Route the case to the practice's formal patient-dismissal and continuity-of-care protocol rather than deciding informally here.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to formal patient-dismissal review"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Repeat broken-appointment policy escalation — A patient reaches a second or third broken appointment in twelve months.",
      "title": "Repeat broken-appointment policy escalation",
      "trigger": "A patient reaches a second or third broken appointment in twelve months",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "sch-013",
      "kind": "operational",
      "materials": [
        "emergency triage notes",
        "reserved emergency block on the template (if used)",
        "day sheet showing current bookings"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "front-desk",
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Before working the caller into today's dental schedule, confirm the concern is a dental emergency and not a life-threatening event. If there are signs of a life-threatening emergency (difficulty breathing, uncontrolled bleeding, facial swelling closing the airway, chest pain, loss of consciousness), tell the caller to call 911 or go to the nearest emergency department immediately — do not attempt to schedule.\n\nWhy: A dental schedule slot is the wrong response to a medical emergency; life-threatening symptoms must be routed to 911/EMS first, before any scheduling logic runs.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm this is not a life-threatening emergency requiring 911/EMS.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Confirm this is not a life-threatening emergency requiring 911/EMS",
          "why": "A dental schedule slot is the wrong response to a medical emergency; life-threatening symptoms must be routed to 911/EMS first, before any scheduling logic runs."
        },
        {
          "detail": "Review the triage note (pain level, swelling, trauma, bleeding controlled at home) confirming same-day is appropriate rather than next-available.\n\nWhy: Not every urgent-sounding call needs today's schedule broken; confirming the triage result avoids unnecessary disruption.",
          "id": "s2",
          "kind": "step",
          "role": "scheduler",
          "title": "Confirm the triage result calls for a same-day dental visit",
          "why": "Not every urgent-sounding call needs today's schedule broken; confirming the triage result avoids unnecessary disruption."
        },
        {
          "detail": "Is there a reserved emergency block open today?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "block-open",
              "label": "Reserved emergency block has room today"
            },
            {
              "goto": "s7",
              "id": "no-block",
              "label": "No reserved block, or it is already used"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "scheduler",
          "title": "Is there a reserved emergency block open today?"
        },
        {
          "detail": "Place the patient into the reserved same-day emergency slot and note the chief concern for the clinical team.\n\nRecord: Appointment booked in the emergency block with chief concern noted.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Book the patient into the reserved emergency block"
        },
        {
          "detail": "Tell the assistant and dentist the emergency patient's arrival time and chief concern so the operatory can be prepped.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Notify the clinical team of the added patient"
        },
        {
          "detail": "Same-day emergency patient worked into the schedule",
          "id": "s6",
          "kind": "step",
          "role": "scheduler",
          "title": "Same-day emergency patient worked into the schedule"
        },
        {
          "detail": "How should the patient be worked in without a reserved block?\n\nWhy: Fitting an emergency into a full day always trades against an already-scheduled patient, so the option chosen should minimize harm.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "shorten-existing",
              "label": "Shorten a lower-acuity appointment to make room"
            },
            {
              "goto": "s8",
              "id": "double-book",
              "label": "Double-book with an assistant covering both chairs"
            },
            {
              "goto": "s8",
              "id": "add-to-end",
              "label": "Add to the end of the day past normal hours"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "scheduler",
          "title": "How should the patient be worked in without a reserved block?",
          "why": "Fitting an emergency into a full day always trades against an already-scheduled patient, so the option chosen should minimize harm."
        },
        {
          "detail": "The dentist reviews the proposed change (shortened appointment, double-booking, or extended day) and confirms it is workable before the scheduler commits it.\n\nWhy: Only the treating dentist can judge whether shortening another patient's time or adding a same-day emergency is clinically appropriate for that day's mix of patients.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms the schedule change is clinically and operationally acceptable.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms the schedule change is clinically and operationally acceptable",
          "why": "Only the treating dentist can judge whether shortening another patient's time or adding a same-day emergency is clinically appropriate for that day's mix of patients."
        },
        {
          "detail": "Schedule the patient into the approved slot and note which existing appointment, if any, was shortened or moved and why.\n\nRecord: Appointment booked; note on which existing appointment was affected and the dentist's approval.",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Book the emergency patient into the agreed slot"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Working a same-day emergency patient into a full schedule — Emergency call triage says same-day and the day is already full.",
      "title": "Working a same-day emergency patient into a full schedule",
      "trigger": "Emergency call triage says same-day and the day is already full",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "sch-014",
      "kind": "operational",
      "materials": [
        "schedule with remaining time in the appointment block",
        "next patient's appointment time",
        "late-arrival policy"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Note how many minutes late the patient is and how much time remains in their booked block before the next patient.\n\nWhy: The decision depends entirely on remaining time versus what the procedure needs, so this has to be established first.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the actual arrival time against the scheduled time",
          "why": "The decision depends entirely on remaining time versus what the procedure needs, so this has to be established first."
        },
        {
          "detail": "Is there enough time left to safely complete the planned procedure?\n\nWhy: Rushing a clinical procedure to protect the schedule is a quality and safety risk, not just a convenience trade-off.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "enough-time",
              "label": "Enough time remains to complete the visit as planned"
            },
            {
              "goto": "s3",
              "id": "partial-time",
              "label": "Only enough time for a shortened version of the visit"
            },
            {
              "goto": "s3",
              "id": "no-time",
              "label": "Not enough time to see the patient at all without delaying the next patient"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is there enough time left to safely complete the planned procedure?",
          "why": "Rushing a clinical procedure to protect the schedule is a quality and safety risk, not just a convenience trade-off."
        },
        {
          "detail": "Tell the dentist or hygienist how late the patient is and how much time remains; ask whether to proceed as originally planned, shorten the visit, do a partial procedure, or reschedule — even when front-desk's read is that enough time remains, the provider confirms before the patient is brought back.\n\nWhy: Only the treating provider can judge whether proceeding, a shortened visit, or a reschedule is clinically appropriate for this patient's planned procedure — front-desk's time math is an input to that call, not a substitute for it.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Consult the provider on options",
          "why": "Only the treating provider can judge whether proceeding, a shortened visit, or a reschedule is clinically appropriate for this patient's planned procedure — front-desk's time math is an input to that call, not a substitute for it."
        },
        {
          "detail": "Provider decides: proceed, shorten, partial, or reschedule",
          "forks": [
            {
              "goto": "s7",
              "id": "proceed",
              "label": "Enough time — proceed with the visit as originally planned"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "shorten",
              "label": "Shorten the visit to fit remaining time"
            },
            {
              "goto": "s8",
              "id": "reschedule",
              "label": "Not enough time — reschedule the patient"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Provider decides: proceed, shorten, partial, or reschedule"
        },
        {
          "detail": "Note what was completed today and book a follow-up for any part of the planned procedure that had to be deferred.\n\nRecord: Chart note: late arrival, portion completed, portion deferred with follow-up date.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the shortened visit and reschedule any deferred portion"
        },
        {
          "detail": "Late-arrival decision complete",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Late-arrival decision complete"
        },
        {
          "detail": "Room the patient and notify the provider that the visit can proceed on the original plan.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Bring the patient back and proceed with the visit"
        },
        {
          "detail": "Rebook the patient for the next available slot and note the late arrival in the chart for pattern tracking.\n\nRecord: Chart note: late arrival led to reschedule, new appointment date noted.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to rebooking and note the pattern"
        },
        {
          "detail": "Is this a repeat late-arrival pattern for this patient?",
          "forks": [
            {
              "goto": "s10",
              "id": "repeat-pattern",
              "label": "Patient has a repeat late-arrival history"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "isolated",
              "label": "This appears to be an isolated occurrence"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this a repeat late-arrival pattern for this patient?"
        },
        {
          "detail": "Add a flag and hand the chart to the office manager to consider whether the repeat broken-appointment escalation protocol applies.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Flag the chart for the broken-appointment escalation protocol"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Patient arrives late — see, shorten or reschedule — A patient arrives more than ten minutes late for the appointment.",
      "title": "Patient arrives late — see, shorten or reschedule",
      "trigger": "A patient arrives more than ten minutes late for the appointment",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "sch-015",
      "kind": "operational",
      "materials": [
        "full day sheet for the affected provider",
        "other providers' availability",
        "patient contact information",
        "outreach script for the disruption"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "office-manager",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Get confirmation from the provider (or whoever is relaying the message) of which day(s) are affected and whether it is one day or open-ended.\n\nWhy: The plan differs for a single-day absence versus a multi-day one, so confirming scope comes first.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the provider's unavailability and expected duration",
          "why": "The plan differs for a single-day absence versus a multi-day one, so confirming scope comes first."
        },
        {
          "detail": "Print or export every appointment on the provider's column for the affected day, in time order, with procedure and contact info.",
          "id": "s2",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull the full list of the day's affected appointments"
        },
        {
          "detail": "Is another qualified provider available to cover any of the day?\n\nWhy: Covering appointments avoids patient disruption entirely and should be checked before defaulting to mass rescheduling.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "coverage-available",
              "label": "Another provider can cover some or all of the day"
            },
            {
              "goto": "s5",
              "id": "no-coverage",
              "label": "No coverage available — full day must be rescheduled"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is another qualified provider available to cover any of the day?",
          "why": "Covering appointments avoids patient disruption entirely and should be checked before defaulting to mass rescheduling."
        },
        {
          "detail": "Match the covering provider's scope (procedures they can perform) against each appointment; anything outside their scope goes to the reschedule list.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Sort the day into covered appointments and appointments needing rescheduling"
        },
        {
          "detail": "Order the reschedule list by urgency: same-day/urgent treatment first, then earliest appointment times, then routine hygiene last.\n\nWhy: Contacting patients in appointment-time order reaches people before they leave for their appointment, minimizing wasted trips.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Prioritize which patients to contact first",
          "why": "Contacting patients in appointment-time order reaches people before they leave for their appointment, minimizing wasted trips."
        },
        {
          "detail": "Call or text each patient, apologize for the disruption, and offer either the covering provider's slot or the earliest available rebooking with the original provider.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact each affected patient"
        },
        {
          "detail": "Were all patients reached before their scheduled time?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "all-reached",
              "label": "Every patient was reached"
            },
            {
              "goto": "s11",
              "id": "some-unreached",
              "label": "Some patients could not be reached in time"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Were all patients reached before their scheduled time?"
        },
        {
          "detail": "Record for each patient whether they were covered, rebooked, or unreached, and the new appointment time if applicable.\n\nRecord: Per-patient outcome log: covered / rebooked / unreached, with new appointment time where applicable.",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Log the outcome for every affected appointment"
        },
        {
          "detail": "Summarize the day's disruption, patients affected, and how many were successfully covered or rebooked versus unreached.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the practice owner of the disruption and outcome"
        },
        {
          "detail": "Provider-out-sick day rescheduling complete",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Provider-out-sick day rescheduling complete"
        },
        {
          "detail": "Have a staff member ready to explain the situation in person and offer immediate rebooking or coverage for anyone who arrives without having been reached.\n\nWhy: A patient who was not reached and arrives to a locked or confused front desk is a worse outcome than a brief in-person explanation.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Station someone at the door to catch unreached arrivals",
          "why": "A patient who was not reached and arrives to a locked or confused front desk is a worse outcome than a brief in-person explanation."
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Provider calls in sick — reschedule the day — A provider becomes unavailable with less than 24 hours' notice and a full column must be moved.",
      "title": "Provider calls in sick — reschedule the day",
      "trigger": "A provider becomes unavailable with less than 24 hours' notice and a full column must be moved",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "daily",
      "id": "sch-016",
      "kind": "operational",
      "materials": [
        "tomorrow's full day sheet",
        "production goal for the day",
        "lab case tracking log",
        "confirmation status per appointment",
        "medical alert flags on patient charts"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "front-desk",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Print or export the complete schedule for the next business day, including patient name, time, procedure, and provider.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull tomorrow's full day sheet for every provider column"
        },
        {
          "detail": "Does tomorrow's scheduled production meet the day's goal?\n\nWhy: Catching a shortfall the day before leaves time to fill gaps; catching it same-day does not.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "meets-goal",
              "label": "Scheduled production meets or exceeds the goal"
            },
            {
              "goto": "s12",
              "id": "below-goal",
              "label": "Scheduled production falls short of the goal"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "scheduler",
          "title": "Does tomorrow's scheduled production meet the day's goal?",
          "why": "Catching a shortfall the day before leaves time to fill gaps; catching it same-day does not."
        },
        {
          "detail": "Walk each provider column for unnecessary holes between patients, back-to-back complex procedures without buffer, and any procedure sequencing that should be reordered (e.g. a hygiene check before a doctor exam that depends on it).",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Check the day for sequencing and column gaps"
        },
        {
          "detail": "Cross-check every appointment requiring a lab case (crown, denture, appliance) against the lab tracking log to confirm the case has arrived.\n\nWhy: A missing lab case discovered at check-in wastes the patient's visit; catching it the day before allows a call to the lab or a reschedule with notice.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm lab cases are in-house for tomorrow's seat/deliver appointments",
          "why": "A missing lab case discovered at check-in wastes the patient's visit; catching it the day before allows a call to the lab or a reschedule with notice."
        },
        {
          "detail": "Is any lab case missing or not yet received?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "all-in",
              "label": "All lab cases confirmed in-house"
            },
            {
              "goto": "s13",
              "id": "case-missing",
              "label": "One or more cases not yet received"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Is any lab case missing or not yet received?"
        },
        {
          "detail": "Identify every patient on tomorrow's sheet who has not confirmed through the standard cascade.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "List every appointment still unconfirmed"
        },
        {
          "detail": "Are there unconfirmed appointments remaining for tomorrow?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "none-unconfirmed",
              "label": "All appointments confirmed"
            },
            {
              "goto": "s14",
              "id": "some-unconfirmed",
              "label": "Unconfirmed appointments remain"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "front-desk",
          "title": "Are there unconfirmed appointments remaining for tomorrow?"
        },
        {
          "detail": "Check each chart for medical alert flags (allergy, anticoagulant use, cardiac history, pregnancy, anxiety flag) and note anything the clinical team needs to see before the patient sits down.\n\nWhy: Surfacing medical alerts the day before, not at check-in, gives the clinical team time to plan (e.g. premedication, extra time, a quieter room) rather than discovering it mid-appointment.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Review medical alert flags for every patient on tomorrow's sheet",
          "why": "Surfacing medical alerts the day before, not at check-in, gives the clinical team time to plan (e.g. premedication, extra time, a quieter room) rather than discovering it mid-appointment."
        },
        {
          "detail": "Compile the day sheet, production total, flagged gaps and fills, lab case status, remaining unconfirmed count, and medical alerts into one huddle sheet for the morning meeting.\n\nRecord: Huddle sheet for tomorrow: production total, gap/fill status, lab status, unconfirmed count, medical alerts by patient.",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Assemble tomorrow's huddle sheet"
        },
        {
          "detail": "Share the completed huddle sheet with the front desk, assistants and providers before the office closes today.",
          "id": "s10",
          "kind": "step",
          "role": "scheduler",
          "title": "Distribute the huddle sheet to the team"
        },
        {
          "detail": "Daily schedule audit for tomorrow complete",
          "id": "s11",
          "kind": "step",
          "role": "scheduler",
          "title": "Daily schedule audit for tomorrow complete"
        },
        {
          "detail": "Pass any open chair time to the quick-fill-from-short-call-list protocol to attempt same-evening or first-thing-tomorrow-morning fills.",
          "id": "s12",
          "kind": "step",
          "role": "scheduler",
          "title": "Hand identified gaps to short-call outreach"
        },
        {
          "detail": "Call the lab for status; if the case truly will not arrive in time, contact the patient today to reschedule the seat/deliver appointment.\n\nRecord: Lab contact outcome and, if applicable, rescheduled appointment date.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact the lab and the patient if the case will not arrive"
        },
        {
          "detail": "Pass the list of still-unconfirmed patients to the patient-still-unconfirmed-24-hours-out protocol for final outreach.",
          "id": "s14",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand remaining unconfirmed appointments to the 24-hour unconfirmed protocol"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Daily schedule audit for tomorrow (goal, gaps, sequencing, lab, unconfirmed, medical alerts) — Each afternoon before the front desk closes — the audit produces tomorrow's huddle sheet.",
      "title": "Daily schedule audit for tomorrow (goal, gaps, sequencing, lab, unconfirmed, medical alerts)",
      "trigger": "Each afternoon before the front desk closes — the audit produces tomorrow's huddle sheet",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "source": "TCPA 47 U.S.C. §227 — consent for automated confirmation texts and calls",
          "url": "https://www.law.cornell.edu/uscode/text/47/227"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 45,
      "frequency": "weekly",
      "id": "sch-017",
      "kind": "operational",
      "materials": [
        "schedule report for the next 14 days",
        "production goal figure",
        "waitlist / short-call list",
        "recall due list",
        "outreach script templates (text and phone)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Run the schedule report for today through day 14, sorted by provider and by day, showing open columns and unfilled hygiene/doctor time.\n\nWhy: A rolling two-week window catches gaps early enough to fill them, but not so far out that the list is full of slots that will self-fill naturally.",
          "id": "s1",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull the 14-day schedule report",
          "why": "A rolling two-week window catches gaps early enough to fill them, but not so far out that the list is full of slots that will self-fill naturally."
        },
        {
          "detail": "For each provider/day, compute open chair-time in dollars against that day's production goal; flag any day below 85% of goal.\n\nWhy: Raw open-hours counts don't tell the office what it's actually losing — comparing against the dollar goal turns a schedule gap into a business number the team will act on.",
          "id": "s2",
          "kind": "step",
          "role": "scheduler",
          "title": "Compare open time against the production goal",
          "why": "Raw open-hours counts don't tell the office what it's actually losing — comparing against the dollar goal turns a schedule gap into a business number the team will act on."
        },
        {
          "detail": "List flagged days largest shortfall first; note which are hygiene columns vs. doctor columns, since the fill sources differ (recall list vs. treatment-plan list).",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Rank flagged days by size of shortfall"
        },
        {
          "detail": "For each flagged day, pull: (1) the short-call/waitlist for that provider, (2) patients overdue for recall in that window, (3) unscheduled treatment plan patients whose procedure fits the open time.\n\nWhy: Working from three sources in a fixed order keeps the list from becoming a random cold-call exercise.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Pull candidate fill sources for each flagged day",
          "why": "Working from three sources in a fixed order keeps the list from becoming a random cold-call exercise."
        },
        {
          "detail": "Choose the outreach channel for this batch",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "text-first",
              "label": "Text first, call anyone who doesn't respond within 4 hours"
            },
            {
              "goto": "s6",
              "id": "call-first",
              "label": "Call every candidate directly"
            },
            {
              "goto": "s6",
              "id": "email-only",
              "label": "Email only, no text or call"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "scheduler",
          "title": "Choose the outreach channel for this batch"
        },
        {
          "detail": "Use the approved text/call script for each source (short-call, recall, unscheduled treatment); offer the specific open date/time, do not send a generic 'call us' message.\n\nWhy: Offering a specific slot converts far better than a generic reminder — the patient can say yes on the spot.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Send outreach using the approved script",
          "why": "Offering a specific slot converts far better than a generic reminder — the patient can say yes on the spot."
        },
        {
          "detail": "Record contact method, time, and outcome (booked / declined / no response) against each candidate in the schedule system's activity log.\n\nRecord: Contact log entries per candidate: method, timestamp, outcome, and slot offered.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Log each contact attempt and outcome"
        },
        {
          "detail": "48 hours after the outreach batch, recheck which flagged slots filled and which remain open.",
          "id": "s8",
          "kind": "timer",
          "role": "scheduler",
          "timer_seconds": 172800,
          "title": "Wait 48 hours, then recheck fill status"
        },
        {
          "detail": "Are flagged slots still open after 48 hours?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "filled",
              "label": "All flagged slots filled — close this week's review"
            },
            {
              "goto": "s12",
              "id": "still-gaps",
              "label": "Some slots remain open — escalate to a second outreach wave"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "scheduler",
          "title": "Are flagged slots still open after 48 hours?"
        },
        {
          "detail": "Give the office manager the filled/unfilled tally, dollar shortfall recovered, and any persistent chronic-gap day (same day/provider flagged three weeks running).\n\nWhy: A chronic gap on the same day/provider is a template problem, not an outreach problem, and belongs on the office manager's radar for the next template review.",
          "id": "s10",
          "kind": "step",
          "role": "scheduler",
          "title": "Hand the week's gap summary to the office manager",
          "why": "A chronic gap on the same day/provider is a template problem, not an outreach problem, and belongs on the office manager's radar for the next template review."
        },
        {
          "detail": "Weekly gap analysis complete",
          "id": "s11",
          "kind": "step",
          "title": "Weekly gap analysis complete"
        },
        {
          "detail": "Widen the candidate pool to any active patient with a matching procedure history, and consider a same-day-discount or courtesy-call offer per practice policy.",
          "id": "s12",
          "kind": "step",
          "role": "scheduler",
          "title": "Run a second outreach wave with a broader candidate pool"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Weekly gap analysis and outreach two weeks out — Weekly review of the next two weeks for open time against production goal.",
      "title": "Weekly gap analysis and outreach two weeks out",
      "trigger": "Weekly review of the next two weeks for open time against production goal",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 60,
      "frequency": "quarterly",
      "id": "sch-018",
      "kind": "operational",
      "materials": [
        "office holiday calendar",
        "provider time-off request form",
        "current appointment book for the requested dates",
        "patient notification template (mail/text/portal)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "scheduler",
        "office-manager",
        "front-desk",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "For the quarterly pass, pull the office's approved holiday calendar for the coming quarter. For an ad hoc request, take the provider's written time-off request with specific dates.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the holiday list or provider time-off request"
        },
        {
          "detail": "Does the request fit the office's time-off policy?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "within-policy",
              "label": "Within allowance and notice window — approve"
            },
            {
              "goto": "s11",
              "id": "outside-policy",
              "label": "Outside allowance or short notice — route to owner for a case-by-case call"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the request fit the office's time-off policy?"
        },
        {
          "detail": "Pull every existing appointment on the closure/absence dates for the affected provider(s) or the whole office.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Check the book for appointments already on the affected dates"
        },
        {
          "detail": "Mark the affected days/columns as closed or provider-out in the schedule so no new bookings land on them, effective immediately.\n\nWhy: Blocking before rebooking existing patients prevents a race where a new caller books into a slot that's about to be cleared.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Block the dates in the schedule template",
          "why": "Blocking before rebooking existing patients prevents a race where a new caller books into a slot that's about to be cleared."
        },
        {
          "detail": "Are there displaced patients to rebook?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "has-displaced",
              "label": "Yes — rebook each one"
            },
            {
              "goto": "s8",
              "id": "no-displaced",
              "label": "No existing appointments on the affected dates"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "scheduler",
          "title": "Are there displaced patients to rebook?"
        },
        {
          "detail": "Call or text each affected patient, explain the closure, and offer two or more alternate dates before the original appointment's clinical urgency window closes.\n\nWhy: Offering alternates rather than just canceling keeps the patient in the schedule instead of losing the visit entirely.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Contact each displaced patient and offer alternate dates",
          "why": "Offering alternates rather than just canceling keeps the patient in the schedule instead of losing the visit entirely."
        },
        {
          "detail": "Record whether each patient was successfully rebooked, declined, or unreachable, with the new date if rebooked.\n\nRecord: Displacement log: patient reference, original date, outcome, new date if rebooked.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the rebook outcome for each displaced patient"
        },
        {
          "detail": "Does the closure need emergency coverage arranged?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "no-coverage-needed",
              "label": "Office fully closed, no coverage promised"
            },
            {
              "goto": "s13",
              "id": "coverage-needed",
              "label": "A covering provider or on-call arrangement is needed"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the closure need emergency coverage arranged?"
        },
        {
          "detail": "Update the office's posted hours (phone greeting, website/portal note, printed sign as applicable) with the closure dates and, if arranged, on-call instructions.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Post the closure to the office calendar and patient-facing channels"
        },
        {
          "detail": "Holiday/vacation schedule build complete",
          "id": "s10",
          "kind": "step",
          "title": "Holiday/vacation schedule build complete"
        },
        {
          "detail": "Practice owner decides whether to approve the exception, given coverage impact and patient-displacement cost.\n\nWhy: Approving time off is a staffing/financial decision that belongs to practice leadership, not the front desk, once it falls outside the written policy.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews an out-of-policy time-off request.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "office-manager",
          "title": "Practice owner reviews an out-of-policy time-off request",
          "why": "Approving time off is a staffing/financial decision that belongs to practice leadership, not the front desk, once it falls outside the written policy."
        },
        {
          "detail": "Owner's decision on the exception",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "owner-approves",
              "label": "Owner approves the exception"
            },
            {
              "goto": "s14",
              "id": "owner-denies",
              "label": "Owner denies — notify the provider and stop"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "office-manager",
          "title": "Owner's decision on the exception"
        },
        {
          "detail": "Confirm the covering provider or answering-service on-call instructions for the closure period, and update the after-hours message/voicemail to reflect it.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Arrange and document covering-provider or on-call contact"
        },
        {
          "detail": "Record the denial reason and date in the time-off log; tell the provider directly, not by leaving it on the schedule.\n\nRecord: Time-off request log: date, provider, status=denied, reason.",
          "id": "s14",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the denial and notify the requesting provider"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Building the holiday and provider-vacation schedule — Quarterly, and whenever a provider requests time off.",
      "title": "Building the holiday and provider-vacation schedule",
      "trigger": "Quarterly, and whenever a provider requests time off",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced",
          "source": "Generic functional equivalent: block/goal-based template, confirmation cascade, short-call list, broken-appointment policy — no scheduling-consultancy system reproduced"
        }
      ],
      "class": "front-office-operations",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "sch-019",
      "kind": "operational",
      "materials": [
        "capacity threshold policy",
        "waitlist intake form",
        "not-accepting-new-patients script",
        "referral-out list of nearby practices (if the office keeps one)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "scheduler",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Front desk checks the current new-patient booking lead time or open-slot count against the office's written capacity threshold (e.g., no new-patient slots inside 6 weeks).\n\nWhy: A written threshold, rather than a gut feeling, keeps the front desk consistent about when to switch from booking to waitlisting.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Recognize the practice is at or past its new-patient capacity threshold",
          "why": "A written threshold, rather than a gut feeling, keeps the front desk consistent about when to switch from booking to waitlisting."
        },
        {
          "detail": "Is the office actually over the capacity threshold right now?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "over-threshold",
              "label": "Yes, confirmed over threshold"
            },
            {
              "goto": "s6",
              "id": "under-threshold",
              "label": "No, a slot is available within policy — book normally instead"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the office actually over the capacity threshold right now?"
        },
        {
          "detail": "Is the caller reporting pain, swelling, or another urgent complaint?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "urgent",
              "label": "Urgent complaint reported"
            },
            {
              "goto": "s7",
              "id": "routine",
              "label": "Routine new-patient request, not urgent"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is the caller reporting pain, swelling, or another urgent complaint?"
        },
        {
          "detail": "Transfer the call to the office's emergency/same-day triage process — capacity limits on routine new-patient booking do not apply to a patient reporting pain or swelling.\n\nWhy: Waitlisting an urgent caller risks a real clinical delay; capacity policy governs routine scheduling, not urgent triage.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand urgent callers to the emergency-appointment protocol instead of the waitlist",
          "why": "Waitlisting an urgent caller risks a real clinical delay; capacity policy governs routine scheduling, not urgent triage."
        },
        {
          "detail": "Capacity call handled",
          "id": "s5",
          "kind": "step",
          "title": "Capacity call handled"
        },
        {
          "detail": "Book the appointment using the normal new-patient booking protocol (not this protocol)",
          "id": "s6",
          "kind": "step",
          "title": "Book the appointment using the normal new-patient booking protocol (not this protocol)"
        },
        {
          "detail": "Tell the caller the practice is not currently able to offer a near-term new-patient appointment, and offer to add them to the waitlist for the next opening.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer the caller a spot on the waitlist"
        },
        {
          "detail": "Does the caller want to join the waitlist?",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "join-waitlist",
              "label": "Yes, add to waitlist"
            },
            {
              "goto": "s11",
              "id": "decline-waitlist",
              "label": "No, caller declines"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the caller want to join the waitlist?"
        },
        {
          "detail": "Record the caller's name, contact number, preferred days/times, and general reason for the visit on the waitlist intake form or system entry.\n\nRecord: Waitlist entry: caller reference, contact info, preferred availability, reason for visit, date added.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Complete the waitlist intake form"
        },
        {
          "detail": "Tell the caller how the practice will reach out when a slot opens (call vs. text) and roughly how long the wait has been running recently, so they aren't left guessing.\n\nWhy: An open-ended 'we'll call you' without a timeframe reads as a brush-off and drives the caller to book elsewhere anyway.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Set a clear expectation for follow-up",
          "why": "An open-ended 'we'll call you' without a timeframe reads as a brush-off and drives the caller to book elsewhere anyway."
        },
        {
          "detail": "Does the office keep a referral-out list to offer?",
          "forks": [
            {
              "advised": true,
              "goto": "s12",
              "id": "has-referral-list",
              "label": "Yes, offer the referral-out list"
            },
            {
              "goto": "s13",
              "id": "no-referral-list",
              "label": "No referral list — close the call politely"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the office keep a referral-out list to offer?"
        },
        {
          "detail": "Read or send the office's list of nearby practices accepting new patients, if the office maintains one, and thank the caller for reaching out.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer the referral-out list to the caller"
        },
        {
          "detail": "Thank the caller for their interest, note that the office is not currently accepting new patients, and invite them to check back later.",
          "id": "s13",
          "kind": "step",
          "role": "front-desk",
          "title": "Close the call politely without a referral list"
        }
      ],
      "subclass": "scheduling-and-confirmations",
      "summary": "Practice at capacity: waitlist intake and not-accepting-new-patients script — New-patient demand exceeds available appointments beyond the practice's threshold.",
      "title": "Practice at capacity: waitlist intake and not-accepting-new-patients script",
      "trigger": "New-patient demand exceeds available appointments beyond the practice's threshold",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        },
        {
          "kind": "regulation",
          "label": "State CPR/BLS requirement for licensure renewal (16 CCR §1016)",
          "source": "State CPR/BLS requirement for licensure renewal (16 CCR §1016)"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "sdb-001",
      "kind": "compliance",
      "materials": [
        "license renewal tracker (spreadsheet or compliance software)",
        "state board licensee portal login",
        "CE certificates of completion",
        "CPR/BLS card",
        "renewal fee payment method"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "dentist",
        "hygienist",
        "assistant",
        "compliance-officer",
        "hr"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Office manager checks the state board licensee portal or the practice's license tracker for every dentist, hygienist and assistant's expiration date and flags anyone entering the 90-day renewal window.\n\nWhy: Late renewal can lapse the license, which is a practice-stopping event for that provider — 90 days gives room to fix a CE shortfall before the deadline.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify each licensee's renewal window",
          "why": "Late renewal can lapse the license, which is a practice-stopping event for that provider — 90 days gives room to fix a CE shortfall before the deadline."
        },
        {
          "detail": "Each licensee pulls certificates for: total CE hours required for the license type, any mandatory-subject hours (e.g. infection control, CPR/BLS), and any board-specific categories (e.g. law and ethics where required).\n\nRecord: CE certificate file, one folder per licensee, dated",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Gather required CE hours and categories"
        },
        {
          "detail": "Confirm the CPR/BLS card has not expired and will not expire before the renewal date; schedule a recertification class if it will.\n\nWhy: CPR/BLS currency is a standalone renewal condition in most states and is checked independently of general CE hours.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify CPR/BLS certification is current",
          "why": "CPR/BLS currency is a standalone renewal condition in most states and is checked independently of general CE hours."
        },
        {
          "detail": "Are CE hours and mandatory categories complete?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "complete",
              "label": "All hours and mandatory categories are documented"
            },
            {
              "goto": "s11",
              "id": "short",
              "label": "Hours or a mandatory category are short"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are CE hours and mandatory categories complete?"
        },
        {
          "detail": "Compliance officer reviews the assembled CE file against the checklist and confirms it would withstand a board CE audit before renewal is submitted.\n\nWhy: A renewal can be approved on the honor system and still fail a later board audit if the backing documentation is incomplete — the sign-off catches that gap now, not during an audit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer signs off on the audit-ready CE file.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer signs off on the audit-ready CE file",
          "why": "A renewal can be approved on the honor system and still fail a later board audit if the backing documentation is incomplete — the sign-off catches that gap now, not during an audit."
        },
        {
          "detail": "Licensee or office manager submits the renewal through the state board portal and pays the renewal fee before the expiration date.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the renewal and pay the fee"
        },
        {
          "detail": "Record the new expiration date, confirmation number, and CE file location in the tracker.\n\nRecord: New expiration date, confirmation number, and CE file location recorded in the license renewal tracker.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the renewal in the tracker"
        },
        {
          "detail": "HR receives the new license expiration date and CE completion record to file in the licensee's personnel record.",
          "id": "s8",
          "kind": "step",
          "role": "hr",
          "title": "Notify HR to update the personnel file"
        },
        {
          "detail": "Board processing typically takes 1-3 weeks; hold a copy of the submission receipt until the confirmed renewal or updated license posts on the public license lookup.",
          "id": "s9",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1209600,
          "title": "Wait for the board's renewal confirmation"
        },
        {
          "detail": "License renewed and CE file archived",
          "id": "s10",
          "kind": "step",
          "title": "License renewed and CE file archived"
        },
        {
          "detail": "Enroll the licensee in an accredited course covering the shortfall; confirm the course provider is board-recognized before paying for it.\n\nWhy: A course from a non-recognized provider does not count toward renewal, so provider recognition is checked before enrollment, not after.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Schedule the missing CE before the deadline",
          "why": "A course from a non-recognized provider does not count toward renewal, so provider recognition is checked before enrollment, not after."
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Dentist, hygienist and assistant license renewal with an audit-ready CE file — A licensee's renewal window opens (90 days out), or the board selects the licensee for a CE audit.",
      "title": "Dentist, hygienist and assistant license renewal with an audit-ready CE file",
      "trigger": "A licensee's renewal window opens (90 days out), or the board selects the licensee for a CE audit",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "sdb-002",
      "kind": "compliance",
      "materials": [
        "current state auxiliary allowable-duties matrix",
        "supervision-level definitions (general, direct, indirect)",
        "job description templates",
        "delegation log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "compliance-officer",
        "assistant",
        "hygienist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Determine whether this review is for a new hire, a newly delegated function, or a change to the state practice act, since each changes what needs to be re-checked.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify what triggered the review"
        },
        {
          "detail": "Retrieve the state board's current list of duties each auxiliary category (registered dental assistant, registered dental hygienist, etc.) may perform, and under what supervision level.\n\nWhy: The matrix changes when the practice act is amended, so the practice's own copy must be checked against the board's current version, not assumed current.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Pull the current allowable-duties matrix",
          "why": "The matrix changes when the practice act is amended, so the practice's own copy must be checked against the board's current version, not assumed current."
        },
        {
          "detail": "Write out each clinical or administrative duty the practice intends this staff member to perform (e.g. coronal polishing, placing sealants, taking radiographs, monitoring nitrous oxide).",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "List the specific duties to be assigned"
        },
        {
          "detail": "For each listed duty, record whether the matrix requires general, direct, or indirect supervision, and whether additional certification (e.g. a radiography permit) is required to perform it.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Match each duty to its required supervision level"
        },
        {
          "detail": "Does the staff member hold every certification the matrix requires for these duties?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "All required certifications are on file and current"
            },
            {
              "goto": "s10",
              "id": "no",
              "label": "A required certification is missing or expired"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the staff member hold every certification the matrix requires for these duties?"
        },
        {
          "detail": "Can the practice actually provide the required supervision level for every shift this duty is performed?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes-super",
              "label": "Supervising dentist or hygienist coverage matches the schedule"
            },
            {
              "goto": "s11",
              "id": "no-super",
              "label": "Coverage gap exists on some shifts"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Can the practice actually provide the required supervision level for every shift this duty is performed?"
        },
        {
          "detail": "Dentist reviews and signs the completed duties-and-supervision matrix for this staff member before any of the listed duties are performed.\n\nWhy: The dentist carries supervisory responsibility for delegated duties, so the sign-off is the dentist's, not the office manager's, even though the office manager assembled the paperwork.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervising dentist signs off on the duties matrix.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Supervising dentist signs off on the duties matrix",
          "why": "The dentist carries supervisory responsibility for delegated duties, so the sign-off is the dentist's, not the office manager's, even though the office manager assembled the paperwork."
        },
        {
          "detail": "File the signed duties-and-supervision matrix in the personnel record and job description.\n\nRecord: Signed duties-and-supervision matrix filed in the staff member's personnel record and referenced in their job description.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "File the signed matrix"
        },
        {
          "detail": "Duties matrix reviewed, signed and on file",
          "id": "s9",
          "kind": "step",
          "title": "Duties matrix reviewed, signed and on file"
        },
        {
          "detail": "Remove the uncertified duty from this staff member's assignment list and schedule the missing training or certification exam.\n\nWhy: Assigning a duty the staff member is not certified for is unlicensed practice risk for both the staff member and the supervising dentist.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Restrict duties until the certification is obtained",
          "why": "Assigning a duty the staff member is not certified for is unlicensed practice risk for both the staff member and the supervising dentist."
        },
        {
          "detail": "Either reschedule the supervising licensee's hours to cover the shift, or move the duty to a shift where supervision is available.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Adjust the schedule or duty assignment to close the coverage gap"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Auxiliary allowable-duties and supervision matrix review — A new assistant or hygienist is hired, a licensed function is delegated, or the practice act changes.",
      "title": "Auxiliary allowable-duties and supervision matrix review",
      "trigger": "A new assistant or hygienist is hired, a licensed function is delegated, or the practice act changes",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §1646–1647 (general anesthesia, moderate sedation, pediatric minimal sedation permits)",
          "source": "CA B&P §1646–1647 (general anesthesia, moderate sedation, pediatric minimal sedation permits)",
          "url": "https://www.dbc.ca.gov/licensees/permits/index.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "sdb-003",
      "kind": "compliance",
      "materials": [
        "sedation permit application form",
        "office facility diagram and emergency equipment inventory",
        "staff CPR/ACLS/PALS certifications",
        "emergency drug kit contents list",
        "permit fee payment method"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Determine which sedation permit level is needed",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "moderate",
              "label": "Moderate (conscious) sedation for adults"
            },
            {
              "goto": "s2",
              "id": "pediatric-minimal",
              "label": "Pediatric minimal sedation"
            },
            {
              "goto": "s2",
              "id": "general",
              "label": "General anesthesia or deep sedation"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "dentist",
          "title": "Determine which sedation permit level is needed"
        },
        {
          "detail": "Pull the board's requirements for the chosen permit level: dentist's training/residency documentation, minimum staff present during sedation, required monitoring equipment, and required emergency drugs and airway equipment.\n\nWhy: Each sedation level has a distinct requirement set — applying at the wrong level, or under-preparing equipment, is the most common reason an application is returned.",
          "id": "s2",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review the permit level's training, staffing and equipment requirements",
          "why": "Each sedation level has a distinct requirement set — applying at the wrong level, or under-preparing equipment, is the most common reason an application is returned."
        },
        {
          "detail": "Verify presence and current-dated stock of: pulse oximeter, blood pressure monitor, EKG monitor (where required), emergency airway kit, emergency drug kit, and a functioning defibrillator appropriate to the permit level.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm required emergency equipment and drugs are on hand"
        },
        {
          "detail": "Confirm current CPR/BLS for all clinical staff and, where the permit level requires it, ACLS or PALS for the dentist and monitoring staff.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm required staff certifications"
        },
        {
          "detail": "Complete the board's application form with facility diagram, equipment inventory, staffing plan, and the dentist's training documentation attached.\n\nRecord: Completed application packet with attachments",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Assemble the permit application packet"
        },
        {
          "detail": "Compliance officer checks the packet against the requirement checklist item by item; dentist confirms every clinical representation in the application is accurate.\n\nWhy: A misstatement on a sedation permit application — even unintentional — is treated far more seriously by the board than an incomplete one, so accuracy is checked before, not after, submission.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer and dentist jointly review the packet before submission.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer and dentist jointly review the packet before submission",
          "why": "A misstatement on a sedation permit application — even unintentional — is treated far more seriously by the board than an incomplete one, so accuracy is checked before, not after, submission."
        },
        {
          "detail": "Submit through the board's application channel and pay the required fee; retain a copy of everything submitted.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Submit the application and pay the permit fee"
        },
        {
          "detail": "Most permit levels require an on-site evaluation before the permit is issued — see the companion inspection-prep protocol (sdb-004) once the board contacts the office to schedule it.",
          "id": "s8",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1209600,
          "title": "Await scheduling of the board's site evaluation"
        },
        {
          "detail": "Record the application date, permit number, and renewal date in the compliance tracker.\n\nRecord: Application date, permit number once issued, and renewal date recorded in the compliance tracker.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the permit status and renewal date"
        },
        {
          "detail": "Sedation permit application complete and tracked to renewal",
          "id": "s10",
          "kind": "step",
          "title": "Sedation permit application complete and tracked to renewal"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "General anesthesia, moderate sedation or pediatric minimal sedation permit application and renewal — The practice plans to administer sedation beyond nitrous oxide and local anesthesia, or the permit renewal date approaches.",
      "title": "General anesthesia, moderate sedation or pediatric minimal sedation permit application and renewal",
      "trigger": "The practice plans to administer sedation beyond nitrous oxide and local anesthesia, or the permit renewal date approaches",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §1646–1647 (general anesthesia, moderate sedation, pediatric minimal sedation permits)",
          "source": "CA B&P §1646–1647 (general anesthesia, moderate sedation, pediatric minimal sedation permits)",
          "url": "https://www.dbc.ca.gov/licensees/permits/index.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "sdb-004",
      "kind": "compliance",
      "materials": [
        "inspection date confirmation letter",
        "equipment inventory checklist",
        "emergency drug expiration log",
        "staff certification files",
        "mock code drill log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm in writing the scheduled inspection date and whether it covers general anesthesia, moderate sedation, or pediatric minimal sedation equipment and records.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the inspection date and scope"
        },
        {
          "detail": "Check every item on the permit-level equipment list is present and functional, and every emergency drug and airway supply is within its expiration date.\n\nWhy: The board's inspection is essentially the same checklist run by someone else — finding a gap in the self-audit is far cheaper than finding it during the real inspection.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Run the equipment and drug self-audit",
          "why": "The board's inspection is essentially the same checklist run by someone else — finding a gap in the self-audit is far cheaper than finding it during the real inspection."
        },
        {
          "detail": "Are any drugs, supplies, or equipment expired or non-functional?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean",
              "label": "Everything current and functional"
            },
            {
              "goto": "s11",
              "id": "gaps",
              "label": "One or more items expired or malfunctioning"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are any drugs, supplies, or equipment expired or non-functional?"
        },
        {
          "detail": "Confirm CPR/BLS and (where required) ACLS/PALS certifications for all clinical staff are current, and that sedation training records for the dentist are on file and accessible.",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Verify staff certification and training records are current and filed"
        },
        {
          "detail": "Walk the team through a simulated sedation emergency (e.g. airway obstruction or oversedation) to confirm everyone knows their role and where equipment is located.\n\nWhy: The inspection evaluates the office's ability to respond, not just the presence of equipment — a drill surfaces gaps a static checklist cannot.\n\nRecord: Mock drill date, scenario, and participant list",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Run a mock emergency response drill",
          "why": "The inspection evaluates the office's ability to respond, not just the presence of equipment — a drill surfaces gaps a static checklist cannot."
        },
        {
          "detail": "Walk the treatment room and equipment storage the way an inspector would, checking accessibility, cleanliness, and that posted permits and licenses are current and visible.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Conduct a facility walkthrough as the inspector would see it"
        },
        {
          "detail": "Dentist reviews the completed self-audit, records check, and drill log and confirms the practice is ready to present for inspection.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms readiness before the inspection date.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms readiness before the inspection date"
        },
        {
          "detail": "Greet the inspector, present requested records and equipment, and answer questions directly without volunteering unrelated information.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Host the inspection"
        },
        {
          "detail": "Record the inspection date, outcome, and any corrective actions with due dates.\n\nRecord: Inspection date, outcome, and any required corrective actions with their due dates, filed in the compliance tracker.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the inspection outcome and any corrective actions"
        },
        {
          "detail": "Inspection completed and outcome recorded",
          "id": "s10",
          "kind": "step",
          "title": "Inspection completed and outcome recorded"
        },
        {
          "detail": "Order replacement supplies or service the equipment before the inspection date; do not wait for the inspection to surface the gap.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Replace or restock the flagged items"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Preparing for the board's on-site sedation/anesthesia inspection and evaluation — The board schedules an on-site inspection or the periodic re-evaluation is due.",
      "title": "Preparing for the board's on-site sedation/anesthesia inspection and evaluation",
      "trigger": "The board schedules an on-site inspection or the periodic re-evaluation is due",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA Business & Professions Code §1680(z) — licensee must report to the Dental Board, within 7 days, a patient death related to dental treatment or an unscheduled hospitalization/emergency removal following oral conscious sedation, conscious sedation, or general anesthesia",
          "source": "CA Business & Professions Code §1680(z) — licensee must report to the Dental Board, within 7 days, a patient death related to dental treatment or an unscheduled hospitalization/emergency removal following oral conscious sedation, conscious sedation, or general anesthesia",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "sdb-005",
      "kind": "compliance",
      "materials": [
        "emergency contact list (911, malpractice carrier, defense counsel)",
        "board adverse-event report form",
        "incident timeline template",
        "record preservation checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "compliance-officer",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If the patient is still in the office or the event is in progress, call 911 immediately and begin the office's emergency response (airway, monitoring, reversal agents as trained) before any paperwork or board-notification step begins.\n\nWhy: The patient's safety is handled by the clinical emergency protocol first; this protocol governs what happens after the medical emergency is under EMS or hospital care.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 / activate EMS immediately — this comes before any reporting step.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Call 911 / activate EMS immediately — this comes before any reporting step",
          "why": "The patient's safety is handled by the clinical emergency protocol first; this protocol governs what happens after the medical emergency is under EMS or hospital care."
        },
        {
          "detail": "Confirm handoff to EMS or the receiving hospital is complete and get the transport/hospital destination before shifting attention to reporting.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the patient is with EMS or hospital care"
        },
        {
          "detail": "Practice owner is notified of the event and contacts the malpractice carrier's emergency line; carrier guidance is followed for any subsequent communication.\n\nWhy: The carrier's incident-response guidance often shapes exactly what is documented and said next, so it is obtained before free-form notes are written.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the practice owner and malpractice carrier immediately",
          "why": "The carrier's incident-response guidance often shapes exactly what is documented and said next, so it is obtained before free-form notes are written."
        },
        {
          "detail": "Make a secured, unedited copy of the sedation monitoring record, medication log, and chart entries from the visit; do not add, delete, or amend any entry after the event.\n\nWhy: Post-event alteration of a record is itself a separate, severely sanctioned violation — preservation must happen before any addendum is even considered.\n\nRecord: Time-stamped preserved copy of the full sedation and treatment record",
          "id": "s4",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Preserve the sedation and treatment record unaltered",
          "why": "Post-event alteration of a record is itself a separate, severely sanctioned violation — preservation must happen before any addendum is even considered."
        },
        {
          "detail": "Document what happened, in sequence, with times: sedation given, monitoring readings, first sign of the adverse event, response actions taken, and time EMS was called and arrived.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Build a factual timeline of the event"
        },
        {
          "detail": "Defense counsel or the malpractice carrier's designated reviewer reviews the timeline and draft board report before submission.\n\nWhy: The board report is a formal, statutorily-timed filing with legal consequences; reviewing it before filing catches factual or framing errors while there is still time to correct them.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Legal counsel or carrier reviews the report before it is filed.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Legal counsel or carrier reviews the report before it is filed",
          "why": "The board report is a formal, statutorily-timed filing with legal consequences; reviewing it before filing catches factual or framing errors while there is still time to correct them."
        },
        {
          "detail": "Submit the completed adverse-event report to the state dental board within the statutory reporting window for a sedation-related death or hospitalization.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "File the adverse-event report with the board within the statutory window"
        },
        {
          "detail": "Record the report filing date, confirmation number, and a copy of the filed report.\n\nRecord: Report filing date, confirmation number, and a copy of the filed report retained in the compliance file separate from the patient chart.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the filing date and confirmation"
        },
        {
          "detail": "Once the report is filed, the clinical team holds a debrief on the emergency response and equipment readiness, separate from and after the legal/reporting track.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hold an internal debrief once the immediate reporting is complete"
        },
        {
          "detail": "Adverse event reported and record preserved",
          "id": "s10",
          "kind": "step",
          "title": "Adverse event reported and record preserved"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Reporting a sedation-related death or hospitalization to the board (CA: within the statutory window) — A patient dies or is hospitalized following anesthesia or sedation in the office.",
      "title": "Reporting a sedation-related death or hospitalization to the board (CA: within the statutory window)",
      "trigger": "A patient dies or is hospitalized following anesthesia or sedation in the office",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA Health & Safety Code §123145 (record retention) and B&P §1683 (record alteration)",
          "source": "CA Health & Safety Code §123145 (record retention) and B&P §1683 (record alteration)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=123145",
          "url_verified_at": "2026-09-14"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "annual",
      "id": "sdb-006",
      "kind": "compliance",
      "materials": [
        "record retention schedule (adult vs. minor)",
        "record inventory list",
        "secure destruction vendor certificate of destruction",
        "migration/backup verification checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Run the record inventory against the retention schedule to identify charts past the minimum retention period, noting that minor patients' records are retained until the patient reaches majority age plus the standard adult period.\n\nWhy: Minor and adult records run on different clocks from the same statute, so the two categories must be filtered separately before anything is flagged for destruction.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Identify records eligible for review",
          "why": "Minor and adult records run on different clocks from the same statute, so the two categories must be filtered separately before anything is flagged for destruction."
        },
        {
          "detail": "Does the record belong to a patient who was a minor during treatment?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "adult-record",
              "label": "Patient was an adult throughout treatment"
            },
            {
              "goto": "s10",
              "id": "minor-record",
              "label": "Patient was a minor during any treatment covered by the record"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the record belong to a patient who was a minor during treatment?"
        },
        {
          "detail": "Confirm the record is past the standard adult retention period from the last date of service before flagging it eligible.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Apply the adult retention period"
        },
        {
          "detail": "List every record confirmed past its applicable retention period, with patient identifier, last date of service, and calculated eligibility date.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Compile the destruction-eligible record list"
        },
        {
          "detail": "Is this cycle a routine destruction review or a storage system migration?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "routine",
              "label": "Routine annual retention review"
            },
            {
              "goto": "s11",
              "id": "migration",
              "label": "Migrating to a new storage system or vendor"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this cycle a routine destruction review or a storage system migration?"
        },
        {
          "detail": "Compliance officer cross-checks the destruction-eligible list against any open litigation hold, board inquiry, or insurance claim involving those patients, and confirms none apply before approving destruction.\n\nWhy: A record under litigation hold or an open board complaint must not be destroyed even if its retention period has technically passed — destroying it looks like, and can be treated as, spoliation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews the destruction list before anything is destroyed.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews the destruction list before anything is destroyed",
          "why": "A record under litigation hold or an open board complaint must not be destroyed even if its retention period has technically passed — destroying it looks like, and can be treated as, spoliation."
        },
        {
          "detail": "Destroy paper records by shredding and electronic records by secure wipe, using a vendor or method that issues a certificate of destruction.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Destroy approved records via a secure method"
        },
        {
          "detail": "Record the certificate of destruction, date, method, and destroyed-record identifiers.\n\nRecord: Certificate of destruction, date, method, and the list of records destroyed (identifiers only, not chart content) filed in the compliance record — this destruction log is itself retained.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the destruction event"
        },
        {
          "detail": "Retention review complete and destruction log filed",
          "id": "s9",
          "kind": "step",
          "title": "Retention review complete and destruction log filed"
        },
        {
          "detail": "Calculate retention from the date the patient reached the age of majority, not from the last date of service, and confirm the extended period has passed before flagging the record eligible.\n\nWhy: Using the adult clock on a minor's record is the most common retention-schedule error and destroys a record years before it is legally allowed to be destroyed.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Apply the minor retention period",
          "why": "Using the adult clock on a minor's record is the most common retention-schedule error and destroys a record years before it is legally allowed to be destroyed."
        },
        {
          "detail": "Before decommissioning the old storage system, spot-check a sample of migrated records against the source to confirm content, images, and metadata transferred intact.\n\nWhy: A failed or partial migration is indistinguishable from record loss once the old system is shut down, so verification happens before decommissioning, not after.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Verify every retained record transferred and is retrievable",
          "why": "A failed or partial migration is indistinguishable from record loss once the old system is shut down, so verification happens before decommissioning, not after."
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Patient record retention, storage and destruction schedule (adult versus minor rules) — Records reach the retention threshold, storage runs out, or a system migration is planned.",
      "title": "Patient record retention, storage and destruction schedule (adult versus minor rules)",
      "trigger": "Records reach the retention threshold, storage runs out, or a system migration is planned",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "sdb-007",
      "kind": "compliance",
      "materials": [
        "complaint letter or investigator credentials",
        "malpractice/liability carrier contact",
        "defense counsel contact",
        "requested record list template",
        "response log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "office-manager",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Whoever receives the letter or the investigator's visit reads the entire document or request before responding to anything, and notes the stated response deadline.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive and read the complaint letter or investigator's request in full"
        },
        {
          "detail": "Practice owner and the dentist named in the complaint are notified the same day; no substantive response, written or verbal, is given before they are informed.\n\nWhy: An off-the-cuff verbal response to an investigator can become part of the record and is harder to walk back than a delayed, counsel-reviewed written one.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Notify the practice owner and the named dentist immediately",
          "why": "An off-the-cuff verbal response to an investigator can become part of the record and is harder to walk back than a delayed, counsel-reviewed written one."
        },
        {
          "detail": "Report the complaint to the malpractice carrier per the policy's notice requirements and engage the carrier-provided or independent defense counsel before drafting any response.",
          "id": "s3",
          "kind": "step",
          "role": "practice-owner",
          "title": "Contact the malpractice/liability carrier and engage counsel"
        },
        {
          "detail": "Does the notice request patient records?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "records-requested",
              "label": "Records are requested"
            },
            {
              "goto": "s8",
              "id": "no-records",
              "label": "No records requested at this stage"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the notice request patient records?"
        },
        {
          "detail": "Identify exactly which patient(s) and which document types are named in the request; do not release anything broader than what is written, and confirm scope with counsel if ambiguous.\n\nWhy: Releasing records beyond the written request's scope is an independent privacy exposure on top of the underlying complaint.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Scope the records request precisely against the written request",
          "why": "Releasing records beyond the written request's scope is an independent privacy exposure on top of the underlying complaint."
        },
        {
          "detail": "Defense counsel reviews the assembled record set for completeness and any privileged material before it is sent to the board.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Counsel reviews the record set before release.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Counsel reviews the record set before release"
        },
        {
          "detail": "Send the counsel-reviewed record set to the board through the channel specified in the request, before the stated deadline.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Release the reviewed records within the deadline"
        },
        {
          "detail": "Defense counsel typically needs several business days to draft a formal response; hold any further internal action until the draft is ready for the dentist's factual review, while still tracking the board's stated deadline.",
          "id": "s8",
          "kind": "timer",
          "role": "compliance-officer",
          "timer_seconds": 432000,
          "title": "Wait for defense counsel to draft the response"
        },
        {
          "detail": "Defense counsel drafts the formal response to the complaint or investigator's inquiry; the dentist reviews it for factual accuracy before it is finalized.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Counsel drafts the written response"
        },
        {
          "detail": "Dentist reviews the drafted response line by line and confirms every clinical or factual statement is accurate before counsel files it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms factual accuracy before the response is filed.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s10",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms factual accuracy before the response is filed"
        },
        {
          "detail": "Counsel submits the response to the board through the specified channel before the deadline stated in the original notice.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the response within the board's deadline"
        },
        {
          "detail": "Record the complaint date, deadline, records released, and response filed date.\n\nRecord: Complaint date, deadline, records released, response filed date, and current status logged in a matter file separate from patient charts.",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the complaint matter"
        },
        {
          "detail": "Board complaint response filed and matter logged",
          "id": "s13",
          "kind": "step",
          "title": "Board complaint response filed and matter logged"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Responding to a state board complaint letter or investigator contact — The board mails a complaint notification, or an investigator requests records or an interview.",
      "title": "Responding to a state board complaint letter or investigator contact",
      "trigger": "The board mails a complaint notification, or an investigator requests records or an interview",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "sdb-008",
      "kind": "compliance",
      "materials": [
        "posted license/permit wall display",
        "infection-control written protocol",
        "sterilization monitoring log",
        "OSHA/exposure control plan",
        "visitor log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Front desk asks for photo identification and board credentials, and notes the inspector's name and the board division they represent.\n\nWhy: Confirming credentials protects against impersonation and creates the first line of the visit's record.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify the inspector's credentials before granting access",
          "why": "Confirming credentials protects against impersonation and creates the first line of the visit's record."
        },
        {
          "detail": "Front desk pages the office manager and the dentist on duty so a manager is present for the entire visit; the inspector is asked to wait briefly in a non-clinical area.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Notify the office manager and dentist immediately"
        },
        {
          "detail": "Is a patient currently in a treatment room the inspector wants to see?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "no-patient",
              "label": "No patient in the area of interest"
            },
            {
              "goto": "s11",
              "id": "patient-present",
              "label": "A patient is present"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a patient currently in a treatment room the inspector wants to see?"
        },
        {
          "detail": "Office manager or compliance officer accompanies the inspector at all times, presenting the sterilization log, exposure control plan, and posted licenses as requested.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Escort the inspector through the facility"
        },
        {
          "detail": "Does the inspector request to review a specific patient chart?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-chart",
              "label": "No chart requested"
            },
            {
              "goto": "s12",
              "id": "chart-requested",
              "label": "A specific chart is requested"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the inspector request to review a specific patient chart?"
        },
        {
          "detail": "Staff answer only what is asked, factually, without speculating or volunteering unrelated information; if a question is outside their role, they refer it to the office manager or dentist.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Answer the inspector's questions directly and factually"
        },
        {
          "detail": "Listen to any preliminary findings the inspector shares at the end of the visit and ask for anything cited to be put in writing.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Receive the inspector's findings or exit interview"
        },
        {
          "detail": "Record the inspection date, inspector identity, areas reviewed, and corrective actions.\n\nRecord: Inspection date, inspector name and division, areas reviewed, and any corrective actions with due dates logged in the compliance tracker.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the visit and any corrective actions"
        },
        {
          "detail": "Assign each corrective action an owner and due date, and confirm completion before the due date rather than waiting for a follow-up inspection to find it still open.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete and close out any corrective actions by their due date"
        },
        {
          "detail": "Inspection completed and any corrective actions closed",
          "id": "s10",
          "kind": "step",
          "title": "Inspection completed and any corrective actions closed"
        },
        {
          "detail": "Ask the inspector to begin with areas not currently occupied by a patient, or briefly reschedule the order of rooms viewed, without asking the patient to leave early or rushing their care.\n\nWhy: Patient care is not interrupted for an inspection — the inspector's route through the facility is adjusted instead.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Coordinate timing so the inspection does not disrupt patient care",
          "why": "Patient care is not interrupted for an inspection — the inspector's route through the facility is adjusted instead."
        },
        {
          "detail": "Compliance officer confirms the inspector's authority to view the specific chart requested, then provides only that chart, supervised, rather than open access to the records system.\n\nWhy: PHI exposure is limited to exactly what the inspection authorizes — an inspector is shown the requested chart, not given standing access to the record system.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms the request before any chart is shown.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s12",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms the request before any chart is shown",
          "why": "PHI exposure is limited to exactly what the inspection authorizes — an inspector is shown the requested chart, not given standing access to the record system."
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "State board inspector arrives for an infection-control or general inspection — A board inspector presents credentials at the front desk.",
      "title": "State board inspector arrives for an infection-control or general inspection",
      "trigger": "A board inspector presents credentials at the front desk",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "CA B&P §801–802.1 / §805 (malpractice settlement and judgment reporting)",
          "source": "CA B&P §801–802.1 / §805 (malpractice settlement and judgment reporting)",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        },
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "sdb-009",
      "kind": "compliance",
      "materials": [
        "settlement or judgment document",
        "malpractice insurer claim file",
        "board reporting form",
        "certified-mail receipt or e-filing confirmation"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Compare the settlement or judgment amount and event type against the state board's mandatory-reporting threshold and definitions.\n\nWhy: Not every claim resolution is reportable; misjudging the threshold either buries a required report or wastes a filing on a non-reportable event.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "yes-reportable",
              "label": "Meets or exceeds the statutory threshold"
            },
            {
              "goto": "s10",
              "id": "not-reportable",
              "label": "Below threshold or not a covered event type"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does this settlement or judgment meet the statutory reporting threshold?",
          "why": "Not every claim resolution is reportable; misjudging the threshold either buries a required report or wastes a filing on a non-reportable event."
        },
        {
          "detail": "Contact the malpractice insurance carrier's claims department to confirm the final settlement or judgment terms and request the closed-claim file for the board report.\n\nWhy: The carrier's own records are the authoritative source for amount, date, and parties — the practice should not reconstruct these from memory.",
          "id": "s2",
          "kind": "step",
          "role": "practice-owner",
          "title": "Notify the malpractice carrier and request the claim file",
          "why": "The carrier's own records are the authoritative source for amount, date, and parties — the practice should not reconstruct these from memory."
        },
        {
          "detail": "The dentist named in the claim reviews the draft board report for accuracy before it is filed, then the practice owner separately confirms it is ready to submit — this is a licensure-consequential filing and never auto-submitted.\n\nWhy: An inaccurate or incomplete board report can itself become a separate compliance problem; a licensed sign-off catches errors before they become a filed record.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed-provider sign-off on the report before filing.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed-provider sign-off on the report before filing",
          "why": "An inaccurate or incomplete board report can itself become a separate compliance problem; a licensed sign-off catches errors before they become a filed record."
        },
        {
          "detail": "Complete the state board's malpractice reporting form with claimant identity limited to what the form requires, settlement/judgment amount, date, and a factual summary of the underlying allegation.\n\nWhy: The board form asks only for what it needs; minimizing extra narrative reduces PHI exposure in a filing that becomes part of a public or quasi-public record.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "board reporting form"
          ],
          "role": "compliance-officer",
          "title": "Prepare the board reporting form",
          "why": "The board form asks only for what it needs; minimizing extra narrative reduces PHI exposure in a filing that becomes part of a public or quasi-public record."
        },
        {
          "detail": "Calculate the filing deadline from the settlement or judgment date using the state board's reporting window and calendar it with a reminder before the due date.\n\nWhy: Late reporting is itself a separate violation independent of the underlying claim.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the statutory filing deadline",
          "why": "Late reporting is itself a separate violation independent of the underlying claim."
        },
        {
          "detail": "File the completed report with the state dental board by the required method (mail, e-filing, or portal) and retain proof of submission.",
          "id": "s6",
          "kind": "step",
          "role": "practice-owner",
          "title": "Submit the report to the board"
        },
        {
          "detail": "File the submitted report, the proof of delivery, and the insurer claim summary in the compliance file, cross-referenced to the internal incident record.\n\nRecord: compliance file — filed report + delivery proof",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Record the filing and proof of submission"
        },
        {
          "detail": "Confirm to the named dentist and practice owner that the report was filed on time, with a copy of the confirmation.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Notify the dentist and practice owner the filing is complete"
        },
        {
          "detail": "Malpractice settlement/judgment reported to the board",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Malpractice settlement/judgment reported to the board"
        },
        {
          "detail": "Record the claim, the amount, and the reasoning that it falls below the reporting threshold, with the compliance officer's sign-off, in the internal compliance log.\n\nRecord: internal compliance log — determination and rationale",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the non-reportable determination"
        },
        {
          "detail": "No board report required — filed internally",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "No board report required — filed internally"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Reporting a malpractice settlement, judgment or arbitration award to the board — A claim settles or a judgment is entered above the statutory threshold.",
      "title": "Reporting a malpractice settlement, judgment or arbitration award to the board",
      "trigger": "A claim settles or a judgment is entered above the statutory threshold",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "annual",
      "id": "sdb-010",
      "kind": "compliance",
      "materials": [
        "fictitious name permit application",
        "prior permit certificate",
        "sign/signage proof",
        "state board fee payment"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Determine whether the practice needs to file a first-time fictitious name permit or renew an existing one before its expiration date.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-permit",
              "label": "New trade name — first-time application"
            },
            {
              "goto": "s7",
              "id": "renewal",
              "label": "Renewal of an existing permit"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a new fictitious name or a renewal of an existing permit?"
        },
        {
          "detail": "Complete the state board's fictitious name permit application, confirming the proposed trade name does not conflict with board naming rules (e.g. no misleading specialty claims) and that the owning dentist's license number is included.\n\nWhy: Boards restrict trade names that could mislead patients about specialty credentials, so the name is checked against the rule before filing, not after rejection.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "fictitious name permit application"
          ],
          "role": "practice-owner",
          "title": "Prepare the new fictitious name application",
          "why": "Boards restrict trade names that could mislead patients about specialty credentials, so the name is checked against the rule before filing, not after rejection."
        },
        {
          "detail": "Submit the application with the required fee through the board's filing method and retain the confirmation.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "state board fee payment"
          ],
          "role": "practice-owner",
          "title": "Pay the fee and submit the application"
        },
        {
          "detail": "Confirm the exterior sign, website, appointment reminders and patient-facing paperwork all display the exact permitted trade name and the owning dentist's name where required.\n\nWhy: A mismatch between the permit and what patients actually see is a common board finding during routine inspections.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "sign/signage proof"
          ],
          "role": "office-manager",
          "title": "Verify signage and displayed materials match the permitted name",
          "why": "A mismatch between the permit and what patients actually see is a common board finding during routine inspections."
        },
        {
          "detail": "Store the new or renewed permit certificate in the compliance file and calendar the next renewal date.\n\nRecord: compliance file — fictitious name permit certificate + renewal date",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "File the confirmed permit and set the next renewal reminder"
        },
        {
          "detail": "Fictitious name permit active and displayed correctly",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Fictitious name permit active and displayed correctly"
        },
        {
          "detail": "Pull the existing fictitious name permit certificate and confirm the renewal deadline against the compliance calendar.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the current permit's expiration date"
        },
        {
          "detail": "Confirm today's date falls within the board's allowed renewal filing window (not too early, not lapsed).",
          "forks": [
            {
              "advised": true,
              "goto": "s9",
              "id": "within-window",
              "label": "Within the filing window"
            },
            {
              "goto": "s10",
              "id": "lapsed",
              "label": "Permit has already lapsed"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the renewal within the board's filing window?"
        },
        {
          "detail": "Complete the board's renewal form, confirming the trade name and owning dentist information are unchanged or updating them if the practice ownership changed.",
          "id": "s9",
          "kind": "step",
          "materials": [
            "fictitious name permit application",
            "prior permit certificate"
          ],
          "role": "office-manager",
          "title": "Prepare the renewal application"
        },
        {
          "detail": "Stop displaying or advertising under the trade name until a new or reinstated permit is confirmed active; contact the board for reinstatement requirements.\n\nWhy: Operating under an unpermitted trade name is itself a compliance exposure independent of the underlying license.",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Remediate a lapsed permit before continuing to use the trade name",
          "why": "Operating under an unpermitted trade name is itself a compliance exposure independent of the underlying license."
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Fictitious name permit application, renewal and display — The practice adopts a trade name other than the dentist's name, or the permit renewal is due.",
      "title": "Fictitious name permit application, renewal and display",
      "trigger": "The practice adopts a trade name other than the dentist's name, or the permit renewal is due",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "sdb-011",
      "kind": "compliance",
      "materials": [
        "board license verification lookup",
        "physical or digital license/certificate copy",
        "display frame or board",
        "new-hire compliance checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "hr",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Identify whether this run is for a new hire's credential verification, a routine permit-renewal display update, or a patient request to see credentials.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-hire",
              "label": "New licensee is joining the practice"
            },
            {
              "goto": "s8",
              "id": "renewal-update",
              "label": "A permit or license was just renewed"
            },
            {
              "goto": "s9",
              "id": "patient-request",
              "label": "A patient asked to see credentials"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "What triggered this protocol?"
        },
        {
          "detail": "Search the state dental board's public license lookup for the new hire's license number and confirm it is active, unrestricted, and not on probation before they treat any patients.\n\nWhy: A lapsed, suspended, or probationary license discovered after the person has already started treating patients is a far worse exposure than a short delay in start date.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "board license verification lookup"
          ],
          "role": "hr",
          "title": "Verify the new licensee's status on the board's public lookup",
          "why": "A lapsed, suspended, or probationary license discovered after the person has already started treating patients is a far worse exposure than a short delay in start date."
        },
        {
          "detail": "Review the lookup result for probation terms, practice restrictions, or pending discipline.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "clean",
              "label": "License is active and unrestricted"
            },
            {
              "goto": "s11",
              "id": "restricted",
              "label": "License shows restriction, probation, or discipline"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the board record show any restriction, probation, or discipline?"
        },
        {
          "detail": "Obtain a legible copy of the licensee's current license, DEA registration (if prescribing), and any specialty or permit certificates for the personnel file and the display wall.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "physical or digital license/certificate copy"
          ],
          "role": "hr",
          "title": "Collect a copy of the license, DEA registration, and any specialty certificates"
        },
        {
          "detail": "Place the license and required certificates in the designated display location (front office wall or digital display) per the board's display requirement.\n\nWhy: Most state boards require licenses to be posted in a location visible to patients, not merely available on request.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "display frame or board"
          ],
          "role": "office-manager",
          "title": "Post the required credentials where patients can see them",
          "why": "Most state boards require licenses to be posted in a location visible to patients, not merely available on request."
        },
        {
          "detail": "Store the license lookup confirmation date, the credential copy, and the display date in the licensee's personnel file.\n\nRecord: personnel file — license verification + display log",
          "id": "s6",
          "kind": "step",
          "role": "hr",
          "title": "File the verification and copy in the personnel record"
        },
        {
          "detail": "Credentials verified, displayed, and on file",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Credentials verified, displayed, and on file"
        },
        {
          "detail": "Remove the expired license or permit certificate from the display and replace it with the current renewed version.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Swap the expired certificate for the renewed one"
        },
        {
          "detail": "Direct the patient to the posted display, or provide a copy from the personnel file if the credential in question is not on public display.\n\nWhy: Patients have a reasonable expectation of being able to verify who is treating them; a defensive or evasive response damages trust unnecessarily.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Show the patient the displayed or filed credential",
          "why": "Patients have a reasonable expectation of being able to verify who is treating them; a defensive or evasive response damages trust unnecessarily."
        },
        {
          "detail": "Patient credential request resolved",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Patient credential request resolved"
        },
        {
          "detail": "Hand the lookup findings to the practice owner and compliance officer before any further onboarding step; onboarding does not continue on this licensee until they have made and recorded the proceed/defer determination below.\n\nWhy: Employing a licensee under active board discipline without accounting for the monitor terms can expose the practice to its own compliance liability.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Escalate to the practice owner before onboarding proceeds.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Escalate to the practice owner before onboarding proceeds",
          "why": "Employing a licensee under active board discipline without accounting for the monitor terms can expose the practice to its own compliance liability."
        },
        {
          "detail": "Practice owner and compliance officer confirm whether the board's probation, restriction, or monitor terms are compatible with the role being offered and can actually be met by the practice before onboarding continues.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "proceed-with-monitor",
              "label": "Proceed — monitor terms confirmed and the practice can meet them"
            },
            {
              "goto": "s13",
              "id": "defer-onboarding",
              "label": "Do not onboard — defer the start date until the restriction is resolved or terms cannot be met"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Can onboarding proceed under confirmed monitor terms?"
        },
        {
          "detail": "Onboarding deferred pending resolution of the license restriction",
          "id": "s13",
          "kind": "step",
          "role": "practice-owner",
          "title": "Onboarding deferred pending resolution of the license restriction"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "License, permit and certificate display and verification of new hires — A new licensee joins, a permit is renewed, or a patient asks to see credentials.",
      "title": "License, permit and certificate display and verification of new hires",
      "trigger": "A new licensee joins, a permit is renewed, or a patient asks to see credentials",
      "trigger_kind": "onboarding",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "sdb-012",
      "kind": "compliance",
      "materials": [
        "mobile dental unit registration form",
        "equipment sterilization plan",
        "site agreement with host facility",
        "emergency response plan for the mobile site"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Document the planned host sites (schools, nursing facilities, community events), frequency of visits, and services to be delivered off-site.\n\nWhy: The registration and equipment requirements differ depending on scope, so the plan needs to be concrete before applying.",
          "id": "s1",
          "kind": "step",
          "role": "practice-owner",
          "title": "Define the scope of the mobile or portable program",
          "why": "The registration and equipment requirements differ depending on scope, so the plan needs to be concrete before applying."
        },
        {
          "detail": "Check the state board's rules for whether operating outside the fixed practice location requires a distinct mobile dental unit or portable dental program registration.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "registration-required",
              "label": "Separate registration is required"
            },
            {
              "goto": "s10",
              "id": "notification-only",
              "label": "Notification or none required for this scope"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the state require a separate mobile/portable unit registration?"
        },
        {
          "detail": "Complete the registration form covering the responsible dentist, equipment list, sterilization method, and planned host sites.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "mobile dental unit registration form"
          ],
          "role": "compliance-officer",
          "title": "Prepare the mobile dental unit registration application"
        },
        {
          "detail": "Specify how instruments will be sterilized (on-site autoclave or transported to the home office), how sharps and biohazard waste will be handled, and how water quality will be maintained for portable units.\n\nWhy: Infection control off-site is the most common board inspection finding for mobile programs, since the fixed-office controls (dedicated sterilization room, plumbed water lines) don't automatically transfer.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "equipment sterilization plan"
          ],
          "role": "compliance-officer",
          "title": "Document the portable sterilization and infection-control plan",
          "why": "Infection control off-site is the most common board inspection finding for mobile programs, since the fixed-office controls (dedicated sterilization room, plumbed water lines) don't automatically transfer."
        },
        {
          "detail": "Put in writing the host facility's responsibilities (space, power, emergency access) and the practice's responsibilities (equipment, staff, insurance), signed by both parties.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "site agreement with host facility"
          ],
          "role": "practice-owner",
          "title": "Execute a site agreement with the host facility"
        },
        {
          "detail": "The dentist confirms the mobile-site emergency plan (nearest EMS access, emergency medication kit, communication method) is adequate before the registration is submitted, and confirms the same plan is still in place at every subsequent site visit before the first patient of that visit is treated — a mobile setting has less immediate backup than the fixed office.\n\nWhy: Emergency response at a remote site cannot rely on the fixed office's proximity to help; the licensed dentist must confirm the plan closes that gap before patients are treated there.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the mobile-site emergency response plan.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the mobile-site emergency response plan",
          "why": "Emergency response at a remote site cannot rely on the fixed office's proximity to help; the licensed dentist must confirm the plan closes that gap before patients are treated there."
        },
        {
          "detail": "File the completed registration with the board and retain the confirmation of approval before operating the mobile unit.",
          "id": "s7",
          "kind": "step",
          "role": "practice-owner",
          "title": "Submit the registration and pay any fee"
        },
        {
          "detail": "Store the approved registration, the site agreement, the sterilization plan, and the emergency plan in the compliance file.\n\nRecord: compliance file — mobile unit registration + site agreements + emergency plan",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the registration, site agreements, and plans"
        },
        {
          "detail": "Mobile or portable dental program registered and ready to operate",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Mobile or portable dental program registered and ready to operate"
        },
        {
          "detail": "Submit whatever lighter-weight notice the board requires for the specific scope (e.g. occasional off-site screenings) and document it.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File any required notification short of full registration"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Mobile or portable dental unit registration and permit — The practice plans to treat patients at a school, nursing facility or via a mobile van.",
      "title": "Mobile or portable dental unit registration and permit",
      "trigger": "The practice plans to treat patients at a school, nursing facility or via a mobile van",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        },
        {
          "kind": "statute",
          "label": "CA Health & Safety Code §123145 (record retention) and B&P §1683 (record alteration)",
          "source": "CA Health & Safety Code §123145 (record retention) and B&P §1683 (record alteration)"
        },
        {
          "kind": "statute",
          "label": "CA Health & Safety Code §11165.4 — a prescriber must consult the CURES controlled-substance history database before initially prescribing a Schedule II-IV controlled substance, and at least every four months thereafter if it remains part of the treatment plan",
          "source": "CA Health & Safety Code §11165.4 — a prescriber must consult the CURES controlled-substance history database before initially prescribing a Schedule II-IV controlled substance, and at least every four months thereafter if it remains part of the treatment plan",
          "url": "https://law.justia.com/codes/california/code-hsc/division-10/chapter-4/article-1/section-11165-4/"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 180,
      "frequency": "annual",
      "id": "sdb-013",
      "kind": "compliance",
      "materials": [
        "unprofessional-conduct self-audit checklist",
        "sample of recent advertising and website copy",
        "sample of patient chart records",
        "prescribing log sample"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "compliance-officer",
        "dentist",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Set the audit date on the compliance calendar and assign the compliance officer and a licensed dentist to conduct the review together.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Schedule the annual self-audit and assign reviewers"
        },
        {
          "detail": "Check recent advertising, website claims, and any 'specialist' or outcome language against board advertising rules — no false or misleading claims, correct use of specialty titles only where board-recognized.\n\nWhy: Advertising violations are one of the most common board enforcement categories and are entirely within the practice's control to prevent.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "sample of recent advertising and website copy"
          ],
          "role": "compliance-officer",
          "title": "Review current advertising and website copy for compliance",
          "why": "Advertising violations are one of the most common board enforcement categories and are entirely within the practice's control to prevent."
        },
        {
          "detail": "Confirm that auxiliary staff (hygienists, assistants) performed only duties within their permitted scope and under the required level of supervision during the audit period.",
          "id": "s3",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Review supervision and delegation practices"
        },
        {
          "detail": "Pull a sample of recent patient charts and check for complete informed consent documentation, treatment notes, and no unauthorized alterations.\n\nWhy: Record alteration or missing consent documentation is a distinct violation from any clinical error and is straightforward to self-check.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "sample of patient chart records"
          ],
          "role": "compliance-officer",
          "title": "Sample patient records for documentation completeness",
          "why": "Record alteration or missing consent documentation is a distinct violation from any clinical error and is straightforward to self-check."
        },
        {
          "detail": "Check a sample of controlled-substance prescriptions against documented clinical justification and confirm CURES/PDMP checks were performed where required.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "prescribing log sample"
          ],
          "role": "dentist",
          "title": "Review prescribing patterns for controlled substances"
        },
        {
          "detail": "Compile the results of the four review areas and determine whether any findings require remediation.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-findings",
              "label": "No findings — audit clean"
            },
            {
              "goto": "s9",
              "id": "findings-found",
              "label": "One or more findings identified"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Did the audit surface any findings?"
        },
        {
          "detail": "Document the audit date, reviewers, and the clean result in the compliance file.\n\nRecord: compliance file — annual self-audit result",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the clean audit result"
        },
        {
          "detail": "Annual self-audit complete, no findings",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual self-audit complete, no findings"
        },
        {
          "detail": "The dentist reviews each finding to confirm severity and sign off on the remediation plan before it is implemented.\n\nWhy: Some findings (e.g. supervision or prescribing) carry direct licensure exposure and need a licensed clinician's judgment on remediation, not just an administrative fix.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed dentist reviews findings before remediation plan is finalized.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed dentist reviews findings before remediation plan is finalized",
          "why": "Some findings (e.g. supervision or prescribing) carry direct licensure exposure and need a licensed clinician's judgment on remediation, not just an administrative fix."
        },
        {
          "detail": "For each finding, write a corrective action, assign an owner, and set a remediation deadline.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Build and assign the remediation plan"
        },
        {
          "detail": "Document all findings, the remediation plan, owners, and deadlines in the compliance file for follow-up tracking.\n\nRecord: compliance file — audit findings + remediation plan",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the findings and remediation plan"
        },
        {
          "detail": "Annual self-audit complete, remediation plan in progress",
          "id": "s12",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Annual self-audit complete, remediation plan in progress"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Annual unprofessional-conduct self-audit (advertising, supervision, records, prescribing) — The annual compliance calendar date, or after a board enforcement summary.",
      "title": "Annual unprofessional-conduct self-audit (advertising, supervision, records, prescribing)",
      "trigger": "The annual compliance calendar date, or after a board enforcement summary",
      "trigger_kind": "audit",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "sdb-014",
      "kind": "compliance",
      "materials": [
        "incident observation log",
        "schedule for the day",
        "board diversion/impairment program contact information",
        "employee assistance program contact information"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "practice-owner",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "If the observed clinician is currently treating a patient or about to, immediately and calmly stop or prevent that treatment; if the patient or anyone is in immediate physical danger, call 911. This is the first action, before any documentation.\n\nWhy: An impaired clinician actively treating a patient is an immediate physical-safety risk that outranks every documentation or reporting step.",
          "gate": {
            "ack": "I confirm I have completed this step as written: If a patient is in active treatment or immediate danger, stop treatment now.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "If a patient is in active treatment or immediate danger, stop treatment now",
          "why": "An impaired clinician actively treating a patient is an immediate physical-safety risk that outranks every documentation or reporting step."
        },
        {
          "detail": "Pull the practice owner or office manager aside privately — not in front of patients or other staff — and report exactly what was observed, factually and without accusation.\n\nWhy: This is a sensitive personnel and licensure matter; a public confrontation both endangers patients if it escalates and damages the person's due-process standing if the observation turns out to have another explanation.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Privately notify the practice owner or office manager immediately",
          "why": "This is a sensitive personnel and licensure matter; a public confrontation both endangers patients if it escalates and damages the person's due-process standing if the observation turns out to have another explanation."
        },
        {
          "detail": "Write down the specific observed behaviors (e.g. slurred speech, unsteady gait, disorientation), the time, and who else witnessed it — facts only, no diagnosis or speculation about cause.\n\nWhy: A factual, contemporaneous record protects everyone involved — the patients, the observing staff, and the clinician — far better than a delayed or interpretive account.\n\nRecord: incident observation log — factual account, time, witnesses",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Document exactly what was observed, factually",
          "why": "A factual, contemporaneous record protects everyone involved — the patients, the observing staff, and the clinician — far better than a delayed or interpretive account."
        },
        {
          "detail": "The practice owner determines whether the clinician can be relieved of today's patient schedule immediately, and how remaining patients will be covered or rescheduled.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "remove-now",
              "label": "Remove from schedule immediately, reassign or reschedule patients"
            },
            {
              "goto": "s10",
              "id": "cannot-remove-yet",
              "label": "Cannot immediately remove — escalate urgently"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Can the clinician safely be removed from today's schedule?"
        },
        {
          "detail": "Contact remaining patients on the schedule to reschedule, or reassign to another licensed provider if available, without disclosing the reason to patients.\n\nWhy: Patients need continuity of care without being drawn into a personnel matter that is not theirs to know.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "schedule for the day"
          ],
          "role": "office-manager",
          "title": "Reassign or reschedule the affected patient schedule",
          "why": "Patients need continuity of care without being drawn into a personnel matter that is not theirs to know."
        },
        {
          "detail": "Before any board notification or employment action, the compliance officer and practice owner jointly review the documented observation and decide on next steps — this is a licensure- and employment-consequential decision.\n\nWhy: This decision touches both licensure reporting obligations and employment law; joint sign-off ensures neither is handled alone or hastily.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer and practice owner sign off on next steps.",
            "role": "compliance officer + practice owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer and practice owner sign off on next steps",
          "why": "This decision touches both licensure reporting obligations and employment law; joint sign-off ensures neither is handled alone or hastily."
        },
        {
          "detail": "Reach out to the state board's licensee diversion or impairment program and/or the practice's employee assistance program for guidance on next steps and available support for the clinician.\n\nWhy: Most state boards operate a confidential diversion program designed to get an impaired licensee into treatment rather than straight into discipline — using it is both the compliant and the humane path.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "board diversion/impairment program contact information",
            "employee assistance program contact information"
          ],
          "role": "compliance-officer",
          "title": "Contact the board's diversion program and/or employee assistance resources",
          "why": "Most state boards operate a confidential diversion program designed to get an impaired licensee into treatment rather than straight into discipline — using it is both the compliant and the humane path."
        },
        {
          "detail": "Document the full timeline — observation, notification, patient reassignment, and resource contact — in the compliance file.\n\nRecord: compliance file — impairment incident record + resolution",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the full incident record and resolution"
        },
        {
          "detail": "Immediate patient safety secured; incident documented and escalated appropriately",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Immediate patient safety secured; incident documented and escalated appropriately"
        },
        {
          "detail": "If the clinician cannot be immediately relieved (e.g. sole provider present), the compliance officer and practice owner work together to find emergency coverage or close the schedule for the remainder of the day.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Escalate urgently to compliance officer for immediate resolution"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Suspected impaired or unsafe licensed provider — Staff observe a clinician who appears intoxicated, disoriented or unsafe with patients.",
      "title": "Suspected impaired or unsafe licensed provider",
      "trigger": "Staff observe a clinician who appears intoxicated, disoriented or unsafe with patients",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "sdb-015",
      "kind": "compliance",
      "materials": [
        "general supervision authorization checklist",
        "patient exam history records",
        "schedule for the day"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "scheduler",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "When building the schedule, identify any day where hygiene patients are booked but no dentist will be physically present in the office.\n\nWhy: General supervision has specific statutory conditions that don't apply when a dentist is on-site, so this scheduling pattern needs a dedicated check.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "schedule for the day"
          ],
          "role": "scheduler",
          "title": "Flag the schedule day as a general-supervision hygiene day",
          "why": "General supervision has specific statutory conditions that don't apply when a dentist is on-site, so this scheduling pattern needs a dedicated check."
        },
        {
          "detail": "For every patient on the general-supervision day, confirm they have been examined by a dentist within the state's required recency window (e.g. within the prior statutory period) and that the hygiene procedures planned fall within what general supervision permits.\n\nWhy: General supervision typically requires the dentist to have diagnosed and authorized the specific treatment in advance, within a defined recency window — a hygienist cannot initiate new treatment plans unsupervised.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "general supervision authorization checklist",
            "patient exam history records"
          ],
          "role": "hygienist",
          "title": "Check each scheduled patient's eligibility for general supervision",
          "why": "General supervision typically requires the dentist to have diagnosed and authorized the specific treatment in advance, within a defined recency window — a hygienist cannot initiate new treatment plans unsupervised."
        },
        {
          "detail": "Compile the eligibility check results across the day's schedule.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "all-eligible",
              "label": "All patients eligible"
            },
            {
              "goto": "s8",
              "id": "some-ineligible",
              "label": "One or more patients not eligible"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Are all scheduled patients eligible for general supervision that day?"
        },
        {
          "detail": "Before leaving the office, the dentist reviews and signs off on the confirmed-eligible patient list and the specific procedures authorized for general supervision that day.\n\nWhy: The dentist's prospective authorization is what makes general supervision lawful in the first place — it cannot be assumed after the fact.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms and authorizes the day's general-supervision plan before leaving.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms and authorizes the day's general-supervision plan before leaving",
          "why": "The dentist's prospective authorization is what makes general supervision lawful in the first place — it cannot be assumed after the fact."
        },
        {
          "detail": "File the dentist's signed authorization and the confirmed-eligible patient list for the day in the compliance record.\n\nRecord: compliance file — general supervision day authorization",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the authorization and eligible patient list"
        },
        {
          "detail": "Confirm how the hygienist can reach the dentist by phone during the day if a patient issue arises, and post the number at the front desk.\n\nWhy: General supervision still requires the dentist to be reachable, not simply absent — a working contact plan is part of the statutory condition.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the emergency contact plan for the dentist while off-site",
          "why": "General supervision still requires the dentist to be reachable, not simply absent — a working contact plan is part of the statutory condition."
        },
        {
          "detail": "General-supervision day authorized and documented",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "General-supervision day authorized and documented"
        },
        {
          "detail": "Move any patient who does not meet the general-supervision recency or authorization requirement to a day when a dentist is physically in the office.",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Reschedule ineligible patients to a day with a dentist present"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Hygiene day with the dentist off-site: general-supervision eligibility check — The schedule shows hygiene patients on a day no dentist will be in the building.",
      "title": "Hygiene day with the dentist off-site: general-supervision eligibility check",
      "trigger": "The schedule shows hygiene patients on a day no dentist will be in the building",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "source": "California Dental Practice Act, Business & Professions Code §1600 et seq., and Dental Board of California regulations 16 CCR Division 10",
          "url": "https://www.dbc.ca.gov/formspubs/laws_regs.shtml"
        }
      ],
      "class": "state-board-recordkeeping",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "sdb-016",
      "kind": "compliance",
      "materials": [
        "board probation order",
        "practice monitor agreement",
        "compliance calendar for probation terms",
        "patient disclosure script"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "compliance-officer",
        "dentist",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Obtain the complete probation order from the licensee and read every term — practice restrictions, required monitor, reporting frequency, and duration.\n\nWhy: Probation terms vary widely case to case; acting on a summary or a partial reading risks missing a specific condition the board will actually check.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "board probation order"
          ],
          "role": "compliance-officer",
          "title": "Receive and read the full board probation order",
          "why": "Probation terms vary widely case to case; acting on a summary or a partial reading risks missing a specific condition the board will actually check."
        },
        {
          "detail": "List each condition of probation separately (e.g. practice monitor required, chart review frequency, prohibited procedures, drug testing, CE requirements) with its own deadline.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "compliance calendar for probation terms"
          ],
          "role": "compliance-officer",
          "title": "Extract every actionable term into a compliance checklist"
        },
        {
          "detail": "Check whether the order requires a board-approved practice monitor to review the licensee's charts or observe practice on a set schedule.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "monitor-required",
              "label": "Practice monitor required"
            },
            {
              "goto": "s5",
              "id": "no-monitor",
              "label": "No monitor required by this order"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the probation order require a practice monitor?"
        },
        {
          "detail": "Identify a monitor meeting the board's qualification requirements, secure board approval of the selection where required, and execute the monitor agreement with a defined review schedule.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "practice monitor agreement"
          ],
          "role": "practice-owner",
          "title": "Identify and formally engage the required practice monitor"
        },
        {
          "detail": "Check whether the specific order requires patients to be informed of the licensee's probationary status before treatment.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "disclosure-required",
              "label": "Disclosure to patients is required"
            },
            {
              "goto": "s8",
              "id": "no-disclosure-required",
              "label": "No patient disclosure required by this order"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Does the probation order require patient disclosure of the probationary status?"
        },
        {
          "detail": "The compliance officer and practice owner review and approve the exact wording and delivery method for patient disclosure before front desk staff begin using it, to ensure it meets the board's requirement without volunteering more than required.\n\nWhy: Disclosure wording is a compliance-consequential communication — under-disclosing fails the order, over-disclosing needlessly damages the licensee's practice, so it needs sign-off before it reaches any patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance sign-off on the patient disclosure approach before use.",
            "role": "compliance officer + practice owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance sign-off on the patient disclosure approach before use",
          "why": "Disclosure wording is a compliance-consequential communication — under-disclosing fails the order, over-disclosing needlessly damages the licensee's practice, so it needs sign-off before it reaches any patient."
        },
        {
          "detail": "Walk front desk staff through the approved disclosure wording and when it must be used (e.g. at scheduling, or at check-in) so it is delivered consistently.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "patient disclosure script"
          ],
          "role": "front-desk",
          "title": "Train front desk staff on the approved disclosure script"
        },
        {
          "detail": "Set recurring reminders for every reporting deadline, monitor review, and renewal date in the probation order for its full duration.\n\nWhy: Probation periods run for months or years; a single upfront checklist without ongoing reminders is how terms get missed midway through.",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Build the ongoing probation-term tracking calendar",
          "why": "Probation periods run for months or years; a single upfront checklist without ongoing reminders is how terms get missed midway through."
        },
        {
          "detail": "Store the probation order, the extracted term checklist, the monitor agreement (if any), the approved disclosure script (if any), and the tracking calendar in the compliance file.\n\nRecord: compliance file — probation order + compliance plan + tracking calendar",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the full probation compliance plan"
        },
        {
          "detail": "Probation terms implemented, monitored, and documented",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Probation terms implemented, monitored, and documented"
        }
      ],
      "subclass": "state-dental-board-licensure-permits-and-records",
      "summary": "Licensee on probation: practice-monitor terms and patient disclosure — A dentist or hygienist in the practice is placed on board probation.",
      "title": "Licensee on probation: practice-monitor terms and patient disclosure",
      "trigger": "A dentist or hygienist in the practice is placed on board probation",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 (Emergency Action Plan) and 1910.39 (Fire Prevention Plan); 1910.157 extinguishers",
          "source": "OSHA 29 CFR 1910.38 (Emergency Action Plan) and 1910.39 (Fire Prevention Plan); 1910.157 extinguishers",
          "url": "https://www.ecfr.gov/current/title-29/part-1910/subpart-E"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.157 portable fire extinguishers",
          "source": "OSHA 29 CFR 1910.157 portable fire extinguishers",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.157"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "site-001",
      "kind": "operational",
      "materials": [
        "fire extinguisher (ABC-rated)",
        "posted evacuation route map",
        "assembly point signage",
        "smoke detector / pull station",
        "incident log form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "dentist",
        "front-desk",
        "practice-owner",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Any staff member who sees flames or smoke, or hears the fire alarm, calls 911 first, states the address and 'fire in a dental office', then pulls the building fire alarm if it is not already sounding.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 immediately.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 immediately"
        },
        {
          "detail": "Whoever is treating a patient immediately stops the procedure, moves sharps and handpieces out of reach, raises the chair, and tells the patient calmly that the office is evacuating.\n\nWhy: A seated patient mid-procedure is the highest-risk person in the room; securing sharps first prevents a second injury during evacuation.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Stop treatment and secure the patient",
          "why": "A seated patient mid-procedure is the highest-risk person in the room; securing sharps first prevents a second injury during evacuation."
        },
        {
          "detail": "Evacuate or verify a small fire is out",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "evacuate",
              "label": "Smoke or fire is visible, or the alarm is confirmed real — evacuate the building"
            },
            {
              "goto": "s11",
              "id": "shelter",
              "label": "A small equipment fire was already put out with a fire extinguisher — verify before re-entry"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Evacuate or verify a small fire is out"
        },
        {
          "detail": "Walk, do not run, to the nearest marked exit using the posted evacuation route; do not use elevators; assist any patient who cannot self-evacuate.\n\nWhy: OSHA 1910.38 requires a marked egress route and prohibits elevator use during a fire evacuation.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Walk to the nearest marked exit",
          "why": "OSHA 1910.38 requires a marked egress route and prohibits elevator use during a fire evacuation."
        },
        {
          "detail": "Bring the day's schedule screen or sign-in sheet only if it costs no delay; assemble at the posted outdoor assembly point away from the building.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Reach the assembly point"
        },
        {
          "detail": "Call every staff name on today's schedule and count visible patients against the appointment book; tell arriving fire crews immediately if anyone is unaccounted for.\n\nRecord: Roll call result (accounted for / missing) and evacuation time logged on the incident form; no patient names are retained beyond the shift.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Take roll call of staff and patients"
        },
        {
          "detail": "Give the incident commander the building layout, known chemical or gas-tank locations (nitrous, oxygen concentrators), and the missing-person list if any.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the fire department"
        },
        {
          "detail": "Staff and patients do not re-enter the building until the fire department or practice owner confirms it is safe, including any required fire marshal report.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner clears reopening.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner clears reopening"
        },
        {
          "detail": "Record the cause, response actions, any extinguisher use, and any injuries in the facility incident log; schedule extinguisher recharge or replacement if one was used.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Incident closed",
          "id": "s10",
          "kind": "step",
          "title": "Incident closed"
        },
        {
          "detail": "If a small equipment fire was extinguished with a portable extinguisher, ventilate the smoke, keep the spent extinguisher for inspection, and still call the fire department's non-emergency line to confirm there is no hidden spread before resuming work.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm the fire is fully out and ventilate"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Fire or smoke in the office or building — A fire alarm sounds, or staff sees flames or smoke from equipment, a wall or an adjacent suite.",
      "title": "Fire or smoke in the office or building",
      "trigger": "A fire alarm sounds, or staff sees flames or smoke from equipment, a wall or an adjacent suite",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 (Emergency Action Plan) and 1910.39 (Fire Prevention Plan); 1910.157 extinguishers",
          "source": "OSHA 29 CFR 1910.38 (Emergency Action Plan) and 1910.39 (Fire Prevention Plan); 1910.157 extinguishers",
          "url": "https://www.ecfr.gov/current/title-29/part-1910/subpart-E"
        },
        {
          "kind": "public_domain",
          "label": "CDC carbon monoxide poisoning prevention guidance",
          "source": "CDC carbon monoxide poisoning prevention guidance",
          "url": "https://www.cdc.gov/co/index.html"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 10,
      "frequency": "as-needed",
      "id": "site-002",
      "kind": "operational",
      "materials": [
        "carbon monoxide detector",
        "fire department non-emergency contact card",
        "gas utility emergency line number",
        "incident log form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "front-desk",
        "dentist",
        "practice-owner",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Anyone who smells gas or hears the carbon monoxide alarm calls 911 from outside the building (or a cell phone once clear) and tells everyone to leave now; do not flip light switches, use phones inside, or start vehicles near the building — a spark can ignite gas.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 and evacuate — do not use switches.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 and evacuate — do not use switches"
        },
        {
          "detail": "Leave doors open behind you rather than pausing to see if they lock; do not stop to power down equipment; walk directly outside and stay upwind of the building.\n\nWhy: Electrical arcs from switches or equipment shutdown are a known ignition source for leaking gas.",
          "id": "s2",
          "kind": "step",
          "role": "all-staff",
          "title": "Evacuate without triggering ignition sources",
          "why": "Electrical arcs from switches or equipment shutdown are a known ignition source for leaking gas."
        },
        {
          "detail": "If a patient is mid-treatment, stop immediately, help them from the chair, and evacuate together rather than finishing the visit.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Bring patients out with you"
        },
        {
          "detail": "Gather at a location upwind and at least the distance the responding fire department recommends from the building; do not re-enter for any reason, including to retrieve belongings.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Assemble upwind, away from the building"
        },
        {
          "detail": "Call every staff name and count patients present against the schedule; report anyone missing to the fire department the moment they arrive.\n\nRecord: Roll call result and evacuation time logged in the incident form.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm everyone is accounted for"
        },
        {
          "detail": "Give arriving fire crews the suspected leak location if known, and call the gas utility's emergency line once it is safe to do so to request the meter be secured.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to fire department and the gas utility"
        },
        {
          "detail": "The fire department or gas utility must declare the building safe, and the practice owner confirms clearance, before any staff or patient re-enters — gas and carbon monoxide can recur after an apparent clearing.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Do not re-enter until cleared.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Do not re-enter until cleared"
        },
        {
          "detail": "Record the alarm time, evacuation time, and utility response; test or replace the carbon monoxide detector per the manufacturer's guidance before reopening.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident and inspect detectors"
        },
        {
          "detail": "Incident closed",
          "id": "s9",
          "kind": "step",
          "title": "Incident closed"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Natural gas odor or carbon monoxide alarm — Staff smells gas, or the carbon monoxide detector alarms.",
      "title": "Natural gas odor or carbon monoxide alarm",
      "trigger": "Staff smells gas, or the carbon monoxide detector alarms",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC and state/local public-health emergency orders; USGS/CalOES Drop-Cover-Hold On guidance (public domain)",
          "source": "CDC and state/local public-health emergency orders; USGS/CalOES Drop-Cover-Hold On guidance (public domain)"
        },
        {
          "kind": "public_domain",
          "label": "USGS earthquake safety guidance (Drop, Cover, Hold On)",
          "source": "USGS earthquake safety guidance (Drop, Cover, Hold On)",
          "url": "https://www.usgs.gov/programs/earthquake-hazards/earthquake-safety"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "site-003",
      "kind": "operational",
      "materials": [
        "posted evacuation route map",
        "assembly point signage",
        "incident log form",
        "emergency supply kit (water, flashlight, first aid)"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "dentist",
        "assistant",
        "office-manager",
        "front-desk",
        "practice-owner",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "The moment shaking starts, everyone drops to the floor, takes cover under a sturdy surface (or drops beside an interior wall away from windows, cabinets and equipment), and holds on until shaking stops; call 911 immediately if anyone is injured or a fire or gas smell starts once it is safe to move.\n\nWhy: USGS/CalOES guidance: most earthquake injuries come from falling objects, not building collapse, so dropping and covering is the effective first action, not evacuating during shaking.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Drop, Cover, Hold On — call 911 only if there is injury or fire.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Drop, Cover, Hold On — call 911 only if there is injury or fire",
          "why": "USGS/CalOES guidance: most earthquake injuries come from falling objects, not building collapse, so dropping and covering is the effective first action, not evacuating during shaking."
        },
        {
          "detail": "Stop the handpiece, move sharp instruments away from the patient's face, and if possible tip the chair back and shield the patient from falling objects (light, cabinet contents) rather than trying to move them during shaking.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Protect the seated patient"
        },
        {
          "detail": "Assess the building before resuming or evacuating",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "inspect",
              "label": "No visible structural damage or gas odor — inspect further before deciding"
            },
            {
              "goto": "s8",
              "id": "evacuate",
              "label": "Structural damage, gas odor, or strong aftershock risk — evacuate now"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Assess the building before resuming or evacuating"
        },
        {
          "detail": "Look for gas odor, visible cracks in load-bearing walls, damaged utility lines, and broken glass or spilled materials before allowing anyone to move freely.\n\nWhy: Aftershocks and hidden structural damage make an unassessed building unsafe even when nothing looks obviously wrong.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Check for hazards room by room",
          "why": "Aftershocks and hidden structural damage make an unassessed building unsafe even when nothing looks obviously wrong."
        },
        {
          "detail": "Confirm no gas odor, no structural damage, and intact utilities before resuming scheduled treatment; if in doubt, evacuate instead of resuming.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Clear the building for normal operations.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "Clear the building for normal operations"
        },
        {
          "detail": "Record the time, actions taken, any injuries, and equipment or supply damage (autoclaves, compressors, chemical spills) for insurance and reopening records.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Incident closed",
          "id": "s7",
          "kind": "step",
          "title": "Incident closed"
        },
        {
          "detail": "Walk out along the clearest path away from anything that could still fall (shelving, ceiling tile, glass); do not use elevators.",
          "id": "s8",
          "kind": "step",
          "role": "all-staff",
          "title": "Evacuate to the outdoor assembly point"
        },
        {
          "detail": "Gather at the outdoor assembly point, away from the building face, overhead wires, and any structure that could have hidden damage.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Assemble away from the building"
        },
        {
          "detail": "Confirm every staff member and each present patient is accounted for; report anyone missing to responding EMS or fire personnel.\n\nRecord: Roll call outcome and evacuation time logged on the incident form.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Take roll call of staff and patients"
        },
        {
          "detail": "After an evacuation, the practice owner (and a structural inspection where damage is suspected) clears the building before staff or patients re-enter.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner authorizes reopening after evacuation.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner authorizes reopening after evacuation"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Earthquake during clinic hours — Shaking begins with patients in chairs, some mid-procedure.",
      "title": "Earthquake during clinic hours",
      "trigger": "Shaking begins with patients in chairs, some mid-procedure",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §5141.1 Protection from Wildfire Smoke",
          "source": "Cal/OSHA Title 8 §5141.1 Protection from Wildfire Smoke",
          "url": "https://www.dir.ca.gov/title8/5141_1.html"
        },
        {
          "kind": "public_domain",
          "label": "EPA/AirNow Air Quality Index",
          "source": "EPA/AirNow Air Quality Index",
          "url": "https://www.airnow.gov/"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "site-004",
      "kind": "operational",
      "materials": [
        "public air-quality index source",
        "NIOSH-approved N95 respirators",
        "HVAC filter rated for smoke recirculation",
        "operations log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "practice-owner",
        "scheduler",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Look up the local AQI for the office's ZIP code each morning during wildfire season using a public air-quality index source; note whether it is in the Unhealthy (151+) or Hazardous (300+) range.\n\nWhy: Cal/OSHA §5141.1 requires action once AQI for PM2.5 reaches 151, and evacuation warnings can arrive independent of the AQI reading.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Check today's air quality index",
          "why": "Cal/OSHA §5141.1 requires action once AQI for PM2.5 reaches 151, and evacuation warnings can arrive independent of the AQI reading."
        },
        {
          "detail": "Decide the day's response by AQI level",
          "forks": [
            {
              "goto": "s8",
              "id": "moderate",
              "label": "AQI below 151 — normal operations, monitor through the day"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "unhealthy",
              "label": "AQI 151 or higher, or an evacuation warning covers the area — trigger protective measures"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide the day's response by AQI level"
        },
        {
          "detail": "Close outside doors and windows, switch HVAC to recirculate through the highest-rated filter the system supports, and limit strenuous outdoor tasks such as trash runs to short exposures.\n\nWhy: Cal/OSHA §5141.1 requires employers to reduce employee exposure once the AQI for PM2.5 reaches 151.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Reduce outdoor air intake and limit exertion",
          "why": "Cal/OSHA §5141.1 requires employers to reduce employee exposure once the AQI for PM2.5 reaches 151."
        },
        {
          "detail": "Make NIOSH-approved N95 respirators available to any staff member who requests one or must go outside; provide fit guidance if none has been given this season.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Make respiratory protection available"
        },
        {
          "detail": "Tell patients traveling from smoke-affected areas that the office remains open with filtered air, and offer rescheduling without penalty to anyone in a wildfire evacuation zone or with a respiratory condition who prefers to wait.",
          "id": "s5",
          "kind": "step",
          "role": "scheduler",
          "title": "Communicate with patients about air quality"
        },
        {
          "detail": "Is an evacuation warning or order now covering the office?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "none",
              "label": "No evacuation order — continue with protective measures"
            },
            {
              "goto": "s9",
              "id": "order",
              "label": "Evacuation warning or order issued for the office's area"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is an evacuation warning or order now covering the office?"
        },
        {
          "detail": "Protocol complete for the day",
          "id": "s7",
          "kind": "step",
          "title": "Protocol complete for the day"
        },
        {
          "detail": "Re-check the AQI mid-shift since wildfire smoke conditions change quickly; escalate to protective measures if it crosses 151.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Recheck AQI at midday"
        },
        {
          "detail": "Close the office for the duration of the evacuation warning or order, reschedule affected patients, and notify staff of the closure and any pay policy that applies.",
          "id": "s9",
          "kind": "step",
          "role": "practice-owner",
          "title": "Close the office and reschedule the day"
        },
        {
          "detail": "Record the AQI level, the decision made, and any patients rescheduled in the day's operations log.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the closure and AQI reading"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Wildfire smoke or hazardous air-quality day — The air quality index reaches the unhealthy range, or an evacuation warning covers the office's area.",
      "title": "Wildfire smoke or hazardous air-quality day",
      "trigger": "The air quality index reaches the unhealthy range, or an evacuation warning covers the office's area",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §3395 Heat Illness Prevention",
          "source": "Cal/OSHA Title 8 §3395 Heat Illness Prevention",
          "url": "https://www.dir.ca.gov/title8/3395.html"
        },
        {
          "kind": "public_domain",
          "label": "CDC/NIOSH heat stress guidance",
          "source": "CDC/NIOSH heat stress guidance",
          "url": "https://www.cdc.gov/niosh/topics/heatstress/"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "site-005",
      "kind": "operational",
      "materials": [
        "indoor thermometer",
        "drinking water station",
        "portable fans/cooling units",
        "operations log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "scheduler"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Check the day's forecast or heat advisory each morning during a heat event and take an indoor temperature reading in patient care areas and the sterilization room.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the heat advisory and indoor temperature"
        },
        {
          "detail": "Decide whether heat-illness prevention measures are needed",
          "forks": [
            {
              "goto": "s8",
              "id": "normal",
              "label": "Indoor temperature comfortable, no advisory — normal operations"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "trigger",
              "label": "Heat advisory in effect or indoor temperature is climbing"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Decide whether heat-illness prevention measures are needed"
        },
        {
          "detail": "Make cool drinking water freely available to staff and patients in the waiting area and clinical bays; remind staff to hydrate on a routine schedule rather than waiting until thirsty.\n\nWhy: Cal/OSHA §3395 requires accessible water and encourages preventive cool-down periods once heat conditions trigger the standard.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Provide water access",
          "why": "Cal/OSHA §3395 requires accessible water and encourages preventive cool-down periods once heat conditions trigger the standard."
        },
        {
          "detail": "Run available cooling (AC, portable units, fans with cross-ventilation), close blinds on sun-facing windows, and if the space cannot be kept reasonably cool, move heat-generating tasks such as sterilization loads to cooler parts of the day.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Cool the space or shift schedules"
        },
        {
          "detail": "Watch staff and patients for heavy sweating, dizziness, nausea, confusion, or cramping; move anyone with symptoms to a cool area and give water.",
          "id": "s5",
          "kind": "step",
          "role": "all-staff",
          "title": "Watch for heat-illness symptoms"
        },
        {
          "detail": "Confusion, hot or dry skin, very flushed skin, or loss of consciousness are signs of heat stroke — call 911 immediately, move the person to shade or air conditioning, and cool them by pouring or spraying water on the skin and applying ice or cold packs to the neck, armpits and groin. Do not give anything by mouth if they are confused or not fully alert; this is a medical emergency.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 for heat stroke signs.",
            "type": "safety"
          },
          "id": "s6",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 for heat stroke signs"
        },
        {
          "detail": "Record the advisory or indoor temperature reading, measures taken, and any staff or patient symptoms observed in the operations log.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the heat event"
        },
        {
          "detail": "Protocol complete for the day",
          "id": "s8",
          "kind": "step",
          "title": "Protocol complete for the day"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Extreme heat day with or without cooling — Outdoor temperature triggers a heat advisory and indoor temperature is rising.",
      "title": "Extreme heat day with or without cooling",
      "trigger": "Outdoor temperature triggers a heat advisory and indoor temperature is rising",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "DHS/CISA active shooter preparedness guidance (public domain)",
          "source": "DHS/CISA active shooter preparedness guidance (public domain)",
          "url": "https://www.cisa.gov/topics/physical-security/active-shooter-preparedness"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "site-006",
      "kind": "operational",
      "materials": [
        "door locks/barricade-capable furniture",
        "incident log form",
        "trauma-support resource list"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "front-desk",
        "practice-owner",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Anyone who sees a weapon, hears shots, or receives a credible threat calls 911 as soon as it is safe to do so and gives the address, description, and location within the building; do not wait for someone else to call.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 the moment a threat is confirmed.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 the moment a threat is confirmed"
        },
        {
          "detail": "Choose the safest response based on the threat's location",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "leave",
              "label": "A clear escape path exists — leave the building"
            },
            {
              "goto": "s9",
              "id": "hide",
              "label": "No safe escape path — hide and secure the room"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "all-staff",
          "title": "Choose the safest response based on the threat's location"
        },
        {
          "detail": "Leave belongings behind, help any patient who can move leave with you, keep hands visible, and get as far from the building as possible before calling or texting 911 with updates. If a patient is sedated, mobility-limited or otherwise cannot self-evacuate even with help, do not attempt to carry them through an open area — stay with them and go to hide_step instead.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Leave the area and get patients out"
        },
        {
          "detail": "Gather away from the building at a location out of the responding officers' path; do not return for any reason until law enforcement clears the scene.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Regroup at a safe distance"
        },
        {
          "detail": "Follow all officer instructions exactly, keep hands visible, and give the building layout and last known location of the threat and any injured people when asked.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to arriving law enforcement"
        },
        {
          "detail": "Do not resume operations until law enforcement clears the scene and the practice owner authorizes reopening; offer trauma-support resources to staff and patients before normal scheduling resumes.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner authorizes reopening.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner authorizes reopening"
        },
        {
          "detail": "Record the sequence of events, response taken, and any injuries for the incident file and post-incident debrief; preserve the scene as instructed by law enforcement.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Incident closed",
          "id": "s8",
          "kind": "step",
          "title": "Incident closed"
        },
        {
          "detail": "Get out of the intruder's view, lock or barricade the door with available furniture, turn off lights, silence phones and any patient monitors that beep, and stay silent until law enforcement identifies itself by name and badge. If a patient cannot be moved (sedated, mobility-limited, disoriented), a staff member stays with them in the room, out of the doorway sightline, rather than leaving them alone.\n\nWhy: DHS/CISA active shooter guidance treats hiding out of view and blocking entry as the effective response when leaving is not safe.",
          "id": "s9",
          "kind": "step",
          "role": "all-staff",
          "title": "Hide, secure the room, and silence phones",
          "why": "DHS/CISA active shooter guidance treats hiding out of view and blocking entry as the effective response when leaving is not safe."
        },
        {
          "detail": "Do not open the door for anyone except identified law enforcement; keep patients calm and still; if the threat enters the room with no other option, staff and patients may act as a group to disrupt and disable the attacker as a last resort.",
          "id": "s10",
          "kind": "step",
          "role": "all-staff",
          "title": "Wait silently for law enforcement to clear the room"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Active threat or armed intruder — Someone with a weapon enters the office or building, or shots are heard nearby.",
      "title": "Active threat or armed intruder",
      "trigger": "Someone with a weapon enters the office or building, or shots are heard nearby",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "DHS/CISA bomb threat guidance (public domain)",
          "source": "DHS/CISA bomb threat guidance (public domain)",
          "url": "https://www.cisa.gov/topics/physical-security/bomb-threats"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "site-007",
      "kind": "operational",
      "materials": [
        "bomb-threat call checklist",
        "incident log form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "office-manager",
        "all-staff",
        "dentist",
        "practice-owner",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Whoever receives the threat call or finds the suspicious package calls 911 immediately from a phone away from the item; do not use two-way radios or cell phones within the evacuation distance, and do not touch, move, or cover the item — radio signals and physical disturbance can be a detonation risk for some devices.\n\nWhy: DHS/CISA bomb threat guidance warns radio transmissions near a suspicious device can be a detonation risk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 — do not touch the item or use radios/cell phones near it.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Call 911 — do not touch the item or use radios/cell phones near it",
          "why": "DHS/CISA bomb threat guidance warns radio transmissions near a suspicious device can be a detonation risk."
        },
        {
          "detail": "Without hanging up if possible, write down the exact words, voice characteristics, background noise, and the time of the call using a bomb-threat checklist; do not put the caller on speaker where patients can hear.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "If it was a phone call, capture what was said"
        },
        {
          "detail": "Move everyone at least the distance recommended by DHS/CISA guidance for the described device, or the responding department's instruction, away from the item, avoiding any area the caller specifically mentioned or line of sight to the object; do not use a routine fire-drill assembly point if it is close to the item.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Evacuate away from the threat"
        },
        {
          "detail": "Help patients from the chair without stopping to explain details; keep the explanation brief ('we need to step outside for a safety check') to avoid panic in the waiting room.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Move patients calmly"
        },
        {
          "detail": "Confirm every staff member and present patient by name against the schedule at the evacuation distance; report anyone missing to responding officers immediately.\n\nRecord: Roll call outcome and the bomb-threat checklist (call details or package description) logged for the responding department.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Account for everyone at the safe distance"
        },
        {
          "detail": "Give the bomb squad or responding officers the checklist notes or package description, its exact location, and anything moved or touched before evacuation.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off the threat details to law enforcement"
        },
        {
          "detail": "Do not allow re-entry until law enforcement or the bomb squad declares the scene clear and the practice owner confirms it is safe to resume; document the clearance time and the agency's name.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner authorizes reopening after law enforcement clearance.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner authorizes reopening after law enforcement clearance"
        },
        {
          "detail": "Record the threat details, response timeline, and clearance confirmation in the facility incident log.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Incident closed",
          "id": "s9",
          "kind": "step",
          "title": "Incident closed"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Bomb threat call or suspicious package delivered — A caller threatens an explosive, or an unexpected package with wires, leaks or odd labeling arrives.",
      "title": "Bomb threat call or suspicious package delivered",
      "trigger": "A caller threatens an explosive, or an unexpected package with wires, leaks or odd labeling arrives",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "NOAA/Ready.gov severe weather guidance",
          "source": "NOAA/Ready.gov severe weather guidance",
          "url": "https://www.ready.gov/severe-weather"
        },
        {
          "kind": "public_domain",
          "label": "Ready.gov flood safety guidance",
          "source": "Ready.gov flood safety guidance",
          "url": "https://www.ready.gov/floods"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "site-008",
      "kind": "operational",
      "materials": [
        "weather radio or phone alert service",
        "interior shelter room",
        "incident log form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "scheduler",
        "front-desk",
        "dentist",
        "practice-owner",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "When a tornado warning, severe thunderstorm warning, or flash flood warning is issued for the office's area, move patients and staff away from windows and glass doors immediately to an interior room or the lowest level away from exterior walls; call 911 immediately if there is injury or someone is trapped.\n\nWhy: NOAA/Ready.gov severe-weather guidance: flying glass and structural failure at exterior walls are the primary tornado/severe-storm injury risk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Move away from windows — call 911 only for injury.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Move away from windows — call 911 only for injury",
          "why": "NOAA/Ready.gov severe-weather guidance: flying glass and structural failure at exterior walls are the primary tornado/severe-storm injury risk."
        },
        {
          "detail": "Stop treatment, help the patient from the chair, and move together to the interior shelter area, bringing a blanket or drape for head and neck protection from debris if time allows.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Move the patient to shelter"
        },
        {
          "detail": "Determine which hazard is active",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "wind",
              "label": "Tornado or severe wind warning — shelter in the interior room"
            },
            {
              "goto": "s10",
              "id": "flood",
              "label": "Street or building flooding — move to higher ground and away from water"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Determine which hazard is active"
        },
        {
          "detail": "Stay away from windows and remain in the interior shelter area until the warning expires on a weather radio or phone alert, or local officials announce all-clear; do not go outside to check conditions during an active warning.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Stay sheltered until the warning is lifted"
        },
        {
          "detail": "Confirm every staff member and present patient is accounted for once sheltered or relocated; report anyone missing.\n\nRecord: Roll call outcome and shelter location logged in the incident form.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Account for everyone"
        },
        {
          "detail": "Once the warning is lifted, check for broken glass, roof or ceiling damage, standing water, and downed power lines before allowing anyone back into normal work areas.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Check for building damage before resuming"
        },
        {
          "detail": "The practice owner confirms the building is safe, or that a contractor or inspector has cleared any visible damage, before scheduling resumes.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner authorizes resuming operations.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner authorizes resuming operations"
        },
        {
          "detail": "Record the warning type, shelter or relocation actions taken, any damage, and the time operations resumed.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the event"
        },
        {
          "detail": "Incident closed",
          "id": "s9",
          "kind": "step",
          "title": "Incident closed"
        },
        {
          "detail": "Move everyone away from rising water to the highest safe level of the building or outside to higher ground; do not walk or drive through moving water; shut off electrical circuits to any flooded area only if it can be done without standing in water.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Move to higher ground and shut off power to flooded areas if safe"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Severe storm, tornado warning or external flooding — A weather warning is issued for the area during clinic hours, or streets around the office are flooding.",
      "title": "Severe storm, tornado warning or external flooding",
      "trigger": "A weather warning is issued for the area during clinic hours, or streets around the office are flooding",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "DHS/CISA active shooter and bomb threat guidance; FEMA Ready.gov business continuity",
          "source": "DHS/CISA active shooter and bomb threat guidance; FEMA Ready.gov business continuity"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 (Emergency Action Plan)",
          "source": "OSHA 29 CFR 1910.38 (Emergency Action Plan)",
          "url": "https://www.ecfr.gov/current/title-29/part-1910/subpart-E"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 90,
      "frequency": "as-needed",
      "id": "site-009",
      "kind": "operational",
      "materials": [
        "local police non-emergency and 911 numbers",
        "duress code list",
        "door lock hardware",
        "battery radio or phone with alert app",
        "patient sign-in list",
        "window coverings"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "front-desk",
        "all-staff",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If violence, weapons, or an immediate threat is visible or reported nearby, call 911 first and give the address and nature of the threat before doing anything else. If law enforcement has already issued a shelter-in-place order, treat that order as equivalent to a 911 call.\n\nWhy: A building-scale threat outranks every administrative step; the team must not lock a door or check a schedule before the call goes out.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 if there is an active or imminent threat.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 if there is an active or imminent threat",
          "why": "A building-scale threat outranks every administrative step; the team must not lock a door or check a schedule before the call goes out."
        },
        {
          "detail": "Read the police alert or news source for the specific instruction. If ordered to shelter-in-place, or if the threat is between the office and any exit, do not go outside.\n\nWhy: Choosing the wrong direction (walking toward the threat) is the most common cause of harm in these events.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Assess: shelter-in-place or evacuate",
          "why": "Choosing the wrong direction (walking toward the threat) is the most common cause of harm in these events."
        },
        {
          "detail": "Decide based on where the threat is relative to the office and any official order in effect.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "shelter",
              "label": "Shelter-in-place: threat is outside or order says stay"
            },
            {
              "goto": "s12",
              "id": "evacuate",
              "label": "Evacuate away from the threat if a safe route exists and no order says stay"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Shelter-in-place or evacuate away from the threat"
        },
        {
          "detail": "Lock the front door and any side/back entrances. Move patients and staff into interior rooms or hallways away from glass. Turn off visible lights in front rooms if it does not trap anyone.\n\nWhy: Locked doors and reduced visibility are the standard defensive posture recommended in active-threat public guidance.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Lock all exterior doors and move away from windows",
          "why": "Locked doors and reduced visibility are the standard defensive posture recommended in active-threat public guidance."
        },
        {
          "detail": "Silence all phone ringers and pagers. Pause any chairside procedure at a safe stopping point. Instruct patients quietly not to open doors for anyone.\n\nWhy: Noise and an opened door can draw attention to occupied rooms.",
          "id": "s5",
          "kind": "step",
          "role": "all-staff",
          "title": "Silence phones and pause treatment",
          "why": "Noise and an opened door can draw attention to occupied rooms."
        },
        {
          "detail": "Use the day's patient sign-in list and staff schedule to confirm everyone in the building is accounted for in a known room.\n\nWhy: A missing person must be identified immediately so responders can be told exactly who and where.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Take a headcount of staff and patients present",
          "why": "A missing person must be identified immediately so responders can be told exactly who and where."
        },
        {
          "detail": "Watch a battery-powered radio, phone alert app, or official police/city feed for updates. Do not rely on rumors or social media alone.\n\nWhy: Acting on an unofficial 'all clear' has caused people to leave shelter too early in documented incidents.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Monitor official alerts for the all-clear",
          "why": "Acting on an unofficial 'all clear' has caused people to leave shelter too early in documented incidents."
        },
        {
          "detail": "Has an official all-clear been issued",
          "forks": [
            {
              "goto": "s7",
              "id": "not-yet",
              "label": "No official all-clear yet — continue sheltering"
            },
            {
              "advised": true,
              "goto": "s9",
              "id": "cleared",
              "label": "Official all-clear received"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Has an official all-clear been issued"
        },
        {
          "detail": "Unlock doors, notify remaining scheduled patients of any delay, and give staff a short debrief opportunity before resuming clinical work.\n\nWhy: Staff and patients who just sheltered may need a moment before returning to normal pace.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Resume operations and check in with the team",
          "why": "Staff and patients who just sheltered may need a moment before returning to normal pace."
        },
        {
          "detail": "Document: Date, time, nature of the event, decision made (shelter vs. evacuate), duration, and any injuries or property damage, kept in the office incident log.\n\nRecord: Date, time, nature of the event, decision made (shelter vs. evacuate), duration, and any injuries or property damage, kept in the office incident log.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the incident"
        },
        {
          "detail": "Event closed",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Event closed"
        },
        {
          "detail": "Route the team to the office evacuation and roll-call protocol (site-011) for exit routes, muster point and accountability.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand off to the evacuation protocol"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Civil unrest, nearby police activity or ordered lockdown — Law enforcement orders shelter-in-place, or protests or violence erupt near the office.",
      "title": "Civil unrest, nearby police activity or ordered lockdown",
      "trigger": "Law enforcement orders shelter-in-place, or protests or violence erupt near the office",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC and state/local public-health emergency orders (public domain)",
          "source": "CDC and state/local public-health emergency orders (public domain)"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 Aerosol Transmissible Disease standard §5199 (where applicable)",
          "source": "Cal/OSHA Title 8 Aerosol Transmissible Disease standard §5199 (where applicable)",
          "url": "https://www.dir.ca.gov/title8/5199.html"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 240,
      "frequency": "as-needed",
      "id": "site-010",
      "kind": "operational",
      "materials": [
        "state dental board bulletin",
        "county public-health order text",
        "PPE inventory",
        "patient communication templates",
        "telehealth or phone triage line"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "compliance-officer",
        "dentist",
        "scheduler",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Locate the exact text of the state dental board bulletin or county public-health order, note the effective date, and identify what it restricts (procedure types, aerosol-generating procedures, patient volume, PPE level).\n\nWhy: Orders vary in scope; acting on a rumor or a partial summary risks either non-compliance or unnecessary lost revenue.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Read the full order or board bulletin",
          "why": "Orders vary in scope; acting on a rumor or a partial summary risks either non-compliance or unnecessary lost revenue."
        },
        {
          "detail": "Work through the day's and week's schedule with the order's definitions and flag each appointment as must-proceed (pain, infection, trauma), time-sensitive, or postponable.\n\nWhy: This is the clinical judgment step that decides who gets contacted first; it stays with a licensed dentist.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Classify the current schedule as urgent, emergency, or elective",
          "why": "This is the clinical judgment step that decides who gets contacted first; it stays with a licensed dentist."
        },
        {
          "detail": "The treating dentist reviews and signs off on the classification list before front desk or scheduler contacts anyone, confirming it matches the order's criteria.\n\nWhy: Reclassifying patient care under a public-health order is a clinical decision that must never auto-execute from a schedule filter alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the urgent/elective split before contacting patients.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the urgent/elective split before contacting patients",
          "why": "Reclassifying patient care under a public-health order is a clinical decision that must never auto-execute from a schedule filter alone."
        },
        {
          "detail": "Check current PPE stock (masks, gowns, eye protection, high-volume evacuation) against the order's required level; note any shortage and the reorder plan.\n\nWhy: An order that raises the required PPE level makes seeing patients without it a compliance violation, not just a preference.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Confirm PPE and infection-control level meets the order",
          "why": "An order that raises the required PPE level makes seeing patients without it a compliance violation, not just a preference."
        },
        {
          "detail": "Can the office meet the order's requirements today",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "can-comply",
              "label": "PPE and staffing meet the requirement — proceed with urgent/emergency schedule"
            },
            {
              "goto": "s9",
              "id": "cannot-comply",
              "label": "Cannot meet requirements yet — close to all but true emergencies until resolved"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Can the office meet the order's requirements today"
        },
        {
          "detail": "Call or message postponed patients with a rebooking window; confirm urgent/emergency patients understand any new intake screening. Where an AI-drafted message is used, the office reviews and edits it before sending, per AB 3030 disclosure requirements — AI-generated, reviewed by a licensed provider before it reaches a patient.\n\nWhy: Patients need a concrete new plan, not just a cancellation, to stay in the practice's care.",
          "id": "s6",
          "kind": "step",
          "role": "scheduler",
          "title": "Notify affected patients of the schedule change",
          "why": "Patients need a concrete new plan, not just a cancellation, to stay in the practice's care."
        },
        {
          "detail": "Document: Order source and effective date, classification criteria used, PPE gaps found and resolved, and the date full schedule resumed.\n\nRecord: Order source and effective date, classification criteria used, PPE gaps found and resolved, and the date full schedule resumed.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the order and the operational response"
        },
        {
          "detail": "Response documented",
          "id": "s8",
          "kind": "step",
          "role": "practice-owner",
          "title": "Response documented"
        },
        {
          "detail": "Contact every patient scheduled during the restricted period with rebooking information; keep only true dental emergencies (per the dentist's classification) on the calendar.\n\nWhy: Full closure is sometimes the only compliant option; patients still need direct notice rather than silence.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Close to non-emergency care and notify all remaining patients",
          "why": "Full closure is sometimes the only compliant option; patients still need direct notice rather than silence."
        },
        {
          "detail": "Document: Order source and effective date, reason full closure was chosen, and patients notified.\n\nRecord: Order source and effective date, reason full closure was chosen, and patients notified.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the closure decision"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Pandemic or public-health order restricting dental care — A state or county order limits elective dental procedures or imposes new infection-control requirements.",
      "title": "Pandemic or public-health order restricting dental care",
      "trigger": "A state or county order limits elective dental procedures or imposes new infection-control requirements",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plan (evacuation routes, procedures, accounting for employees)",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plan (evacuation routes, procedures, accounting for employees)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.38"
        },
        {
          "kind": "public_domain",
          "label": "FEMA Ready.gov evacuation planning guidance (public domain)",
          "source": "FEMA Ready.gov evacuation planning guidance (public domain)"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "site-011",
      "kind": "operational",
      "materials": [
        "posted evacuation route map",
        "muster point sign or landmark",
        "patient sign-in list or day sheet",
        "instrument-safing supplies (tray cover, sharps container)",
        "flashlight"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "front-desk",
        "dentist",
        "assistant",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the evacuation trigger is fire, gas, or another immediate hazard, confirm 911 has been or is being called (per that hazard's own protocol) before beginning the evacuation sequence.\n\nWhy: Evacuation is often paired with an active hazard; the emergency call must not be skipped because everyone is focused on leaving.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Sound or acknowledge the alarm — call 911 if the hazard itself warrants it.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Sound or acknowledge the alarm — call 911 if the hazard itself warrants it",
          "why": "Evacuation is often paired with an active hazard; the emergency call must not be skipped because everyone is focused on leaving."
        },
        {
          "detail": "If a patient is mid-procedure and it takes only seconds, remove sharp instruments from the mouth and set them down safely; do not pause to place a rubber dam or finish a step. If there is any doubt, leave immediately.\n\nWhy: A few seconds of instrument safety prevents an injury during a hurried exit, but no clinical step is worth delaying evacuation.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Safe the patient in the chair, only if time allows without delay",
          "why": "A few seconds of instrument safety prevents an injury during a hurried exit, but no clinical step is worth delaying evacuation."
        },
        {
          "detail": "Walk with any patient who is mobility-limited, sedated, or disoriented; do not use elevators.\n\nWhy: Patients who arrived for a dental appointment may be sedated or anxious and need direct physical guidance, unlike a typical office evacuation.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Assist patients who need help walking or seeing",
          "why": "Patients who arrived for a dental appointment may be sedated or anxious and need direct physical guidance, unlike a typical office evacuation."
        },
        {
          "detail": "Follow the posted evacuation route map to the designated outdoor muster point, staying clear of the building.\n\nWhy: A pre-planned route avoids bottlenecks and keeps everyone moving toward a single known location.",
          "id": "s4",
          "kind": "step",
          "role": "all-staff",
          "title": "Exit via the posted route to the muster point",
          "why": "A pre-planned route avoids bottlenecks and keeps everyone moving toward a single known location."
        },
        {
          "detail": "At the muster point, call names from the day's patient sign-in sheet and the staff schedule; mark each person present, and note anyone unaccounted for.\n\nWhy: This is the single most important step for responders: knowing exactly who might still be inside.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Take roll call against the day sheet and staff schedule",
          "why": "This is the single most important step for responders: knowing exactly who might still be inside."
        },
        {
          "detail": "Is everyone accounted for",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "all-present",
              "label": "Everyone on the day sheet and schedule is at the muster point"
            },
            {
              "goto": "s10",
              "id": "missing",
              "label": "Someone is unaccounted for"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is everyone accounted for"
        },
        {
          "detail": "Remain at the muster point with the group until fire/EMS or the building's designated safety officer gives an all-clear.\n\nWhy: Re-entering before an official all-clear is a leading cause of secondary injuries in evacuation events.",
          "id": "s7",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 900,
          "title": "Wait at the muster point for the all-clear",
          "why": "Re-entering before an official all-clear is a leading cause of secondary injuries in evacuation events."
        },
        {
          "detail": "Document: Trigger, time alarm sounded, time muster-point headcount completed, whether anyone was unaccounted for, and time of all-clear.\n\nRecord: Trigger, time alarm sounded, time muster-point headcount completed, whether anyone was unaccounted for, and time of all-clear.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the evacuation"
        },
        {
          "detail": "Evacuation closed out",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Evacuation closed out"
        },
        {
          "detail": "Give the name, last known location in the building, and any relevant medical or mobility information to the first responder on scene.\n\nWhy: Responders need this information within the first minutes to search effectively; do not re-enter the building yourself.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Report the missing person to arriving EMS/fire personnel immediately",
          "why": "Responders need this information within the first minutes to search effectively; do not re-enter the building yourself."
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Office evacuation with patient accountability and roll call — Any alarm or hazard requires everyone to leave the suite immediately, including patients mid-treatment.",
      "title": "Office evacuation with patient accountability and roll call",
      "trigger": "Any alarm or hazard requires everyone to leave the suite immediately, including patients mid-treatment",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "DHS/Ready.gov shelter-in-place guidance for chemical, biological or radiological hazards (public domain)",
          "source": "DHS/Ready.gov shelter-in-place guidance for chemical, biological or radiological hazards (public domain)"
        },
        {
          "kind": "regulation",
          "label": "Cal/OSHA Title 8 §5141.1 Wildfire Smoke (indoor air protection during smoke events)",
          "source": "Cal/OSHA Title 8 §5141.1 Wildfire Smoke (indoor air protection during smoke events)",
          "url": "https://www.dir.ca.gov/title8/5141_1.html"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "site-012",
      "kind": "operational",
      "materials": [
        "HVAC shutoff or manual damper",
        "duct tape or door seal material",
        "battery radio or phone alert app",
        "bottled water",
        "posted shelter-in-place room diagram"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "all-staff",
        "office-manager",
        "front-desk",
        "dentist",
        "ems"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "If the external hazard (chemical release, dense smoke, or an active threat outside) makes stepping outdoors clearly more dangerous than staying, or if an official order says shelter-in-place, call 911 to report the situation and confirm the guidance before proceeding.\n\nWhy: Shelter-in-place is only correct when going outside is the greater risk; verifying with 911 or the official order prevents sheltering when evacuation was actually safer.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm the hazard and that staying is safer than leaving — call 911 if unsure.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "office-manager",
          "title": "Confirm the hazard and that staying is safer than leaving — call 911 if unsure",
          "why": "Shelter-in-place is only correct when going outside is the greater risk; verifying with 911 or the official order prevents sheltering when evacuation was actually safer."
        },
        {
          "detail": "Whoever is treating a patient stops the procedure immediately, moves the handpiece and any sharp instruments out of reach, and raises the chair before relocating the patient to the shelter room.\n\nWhy: A patient hurried into another room with a bur, scaler or explorer still near the mouth is an avoidable oral-injury risk during relocation.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Stop treatment and secure sharp instruments before moving",
          "why": "A patient hurried into another room with a bur, scaler or explorer still near the mouth is an avoidable oral-injury risk during relocation."
        },
        {
          "detail": "Gather staff and patients in the office's designated interior room (per the posted shelter-in-place diagram), away from windows, exterior walls, and vents where possible.\n\nWhy: Interior rooms reduce exposure to airborne hazards and outside sightlines during a threat.",
          "id": "s3",
          "kind": "step",
          "role": "all-staff",
          "title": "Move everyone to an interior room away from exterior doors and windows",
          "why": "Interior rooms reduce exposure to airborne hazards and outside sightlines during a threat."
        },
        {
          "detail": "If the hazard is smoke, chemical release, or poor air quality, turn off the HVAC system's outside-air intake and use tape or towels to seal obvious gaps around doors.\n\nWhy: Preventing outside air from entering is the primary defense against airborne hazards when sheltering.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Shut off HVAC intake and seal gaps if the hazard is airborne",
          "why": "Preventing outside air from entering is the primary defense against airborne hazards when sheltering."
        },
        {
          "detail": "Confirm every scheduled patient and staff member is present in the shelter room; give patients a brief, honest update on what is happening and roughly how long it may last.\n\nWhy: Uninformed patients are more likely to attempt to leave, which can be dangerous mid-hazard.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Take a headcount and keep patients calm and informed",
          "why": "Uninformed patients are more likely to attempt to leave, which can be dangerous mid-hazard."
        },
        {
          "detail": "Watch a battery radio or phone alert app for the official all-clear or updated instructions; check in with the group periodically.\n\nWhy: Sheltering has a defined endpoint set by the hazard's source, not by how long the room feels comfortable.",
          "id": "s6",
          "kind": "timer",
          "role": "office-manager",
          "timer_seconds": 1800,
          "title": "Monitor official alerts until cleared",
          "why": "Sheltering has a defined endpoint set by the hazard's source, not by how long the room feels comfortable."
        },
        {
          "detail": "Has an official all-clear or updated instruction arrived",
          "forks": [
            {
              "goto": "s6",
              "id": "not-cleared",
              "label": "No update yet — continue sheltering"
            },
            {
              "advised": true,
              "goto": "s8",
              "id": "cleared",
              "label": "Official all-clear received"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "office-manager",
          "title": "Has an official all-clear or updated instruction arrived"
        },
        {
          "detail": "Turn HVAC intake back on if it was shut off, remove door seals, and resume the day's schedule or begin rescheduling as needed.\n\nWhy: Restoring normal air handling and workflow closes out the event for staff and patients.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Restore HVAC and resume normal operations",
          "why": "Restoring normal air handling and workflow closes out the event for staff and patients."
        },
        {
          "detail": "Document: Hazard type, time sheltering began, time of all-clear, and any patient or staff issues during the event.\n\nRecord: Hazard type, time sheltering began, time of all-clear, and any patient or staff issues during the event.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the shelter-in-place event"
        },
        {
          "detail": "Event closed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Event closed"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Shelter-in-place with patients on site — An external hazard (chemical release, smoke, threat) makes leaving more dangerous than staying.",
      "title": "Shelter-in-place with patients on site",
      "trigger": "An external hazard (chemical release, smoke, threat) makes leaving more dangerous than staying",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 Emergency Action Plan (employee training and drills)",
          "source": "OSHA 29 CFR 1910.38 Emergency Action Plan (employee training and drills)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.38"
        },
        {
          "kind": "public_domain",
          "label": "USGS/CalOES Drop-Cover-Hold On guidance (public domain)",
          "source": "USGS/CalOES Drop-Cover-Hold On guidance (public domain)"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 30,
      "frequency": "quarterly",
      "id": "site-013",
      "kind": "operational",
      "materials": [
        "posted evacuation route map",
        "stopwatch or phone timer",
        "drill sign-in sheet",
        "drill debrief form"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Pick a date and time (twice per calendar year, or sooner if a new hire has not yet drilled) and notify the team it is coming within the week, without giving the exact minute.\n\nWhy: An unannounced-timing drill within a known week tests real readiness while avoiding disrupting an actual patient in the chair.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Schedule the drill for a low-patient-impact time",
          "why": "An unannounced-timing drill within a known week tests real readiness while avoiding disrupting an actual patient in the chair."
        },
        {
          "detail": "Alternate between fire/evacuation and earthquake/drop-cover-hold-on so both are practiced within a year.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "fire",
              "label": "Run the fire/evacuation drill this cycle"
            },
            {
              "goto": "s8",
              "id": "earthquake",
              "label": "Run the earthquake drop-cover-hold-on drill this cycle"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Choose the drill scenario for this cycle"
        },
        {
          "detail": "Announce the drill start, have the team follow the posted evacuation route to the muster point, and time from start to full headcount completion.\n\nWhy: Timing the actual walk exposes route obstacles and slow points before a real fire does.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the evacuation drill and time it",
          "why": "Timing the actual walk exposes route obstacles and slow points before a real fire does."
        },
        {
          "detail": "Confirm everyone participated and reached the expected point (muster point or shelter position); record the elapsed time on the drill sign-in sheet.\n\nWhy: Without a recorded time, the practice cannot tell whether drills are actually improving readiness.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Take headcount and record the drill time",
          "why": "Without a recorded time, the practice cannot tell whether drills are actually improving readiness."
        },
        {
          "detail": "Ask the team what slowed them down, what was confusing about the route or instructions, and note any equipment or signage gaps found.\n\nWhy: The debrief is where the drill actually improves the real protocol, not just checks a compliance box.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Debrief the team on what worked and what didn't",
          "why": "The debrief is where the drill actually improves the real protocol, not just checks a compliance box."
        },
        {
          "detail": "Document: Drill date, scenario run, elapsed time, participants, and any corrective actions identified in the debrief, kept in the compliance training log.\n\nRecord: Drill date, scenario run, elapsed time, participants, and any corrective actions identified in the debrief, kept in the compliance training log.",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the drill for the compliance record"
        },
        {
          "detail": "Drill closed out",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Drill closed out"
        },
        {
          "detail": "Announce the drill start, have everyone drop, cover under sturdy furniture, and hold on for the practiced duration per USGS/CalOES guidance, then proceed to a post-shake check and evacuation if the scenario calls for it.\n\nWhy: Practicing the drop-cover-hold-on motion builds the automatic response needed when real shaking gives no time to think.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Run the drop-cover-hold-on drill and time it",
          "why": "Practicing the drop-cover-hold-on motion builds the automatic response needed when real shaking gives no time to think."
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Semiannual fire and earthquake drill — The scheduled drill date arrives (twice yearly), or a new team member has not yet drilled.",
      "title": "Semiannual fire and earthquake drill",
      "trigger": "The scheduled drill date arrives (twice yearly), or a new team member has not yet drilled",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "FEMA Ready.gov business continuity and post-disaster recovery guidance (public domain)",
          "source": "FEMA Ready.gov business continuity and post-disaster recovery guidance (public domain)"
        },
        {
          "kind": "regulation",
          "label": "OSHA 29 CFR 1910.38 (safe re-occupancy expectations follow the same Emergency Action Plan framework)",
          "source": "OSHA 29 CFR 1910.38 (safe re-occupancy expectations follow the same Emergency Action Plan framework)",
          "url": "https://www.ecfr.gov/current/title-29/section-1910.38"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 180,
      "frequency": "as-needed",
      "id": "site-014",
      "kind": "operational",
      "materials": [
        "building damage checklist",
        "camera or phone for photo documentation",
        "insurance policy contact information",
        "utility shutoff/restoration contacts",
        "patient rescheduling list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "office-manager",
        "scheduler",
        "it-vendor",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Walk the exterior first for visible structural damage, downed lines, or gas odor; only enter the building if it looks safe from outside, and leave immediately if anything looks unstable.\n\nWhy: Entering a structurally compromised building to check on equipment has caused injuries after events that looked minor from the outside.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Do a visible-hazard safety walkthrough before anyone re-enters normally",
          "why": "Entering a structurally compromised building to check on equipment has caused injuries after events that looked minor from the outside."
        },
        {
          "detail": "Does the building appear safe to enter and assess further",
          "forks": [
            {
              "goto": "s11",
              "id": "unsafe",
              "label": "Visible structural damage, gas odor, or downed lines — do not enter, call utilities/fire"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "safe-enough",
              "label": "No visible hazard — proceed with interior assessment"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the building appear safe to enter and assess further"
        },
        {
          "detail": "Check water intrusion, power and HVAC function, sterilization equipment integrity, refrigerated medication/material storage temperature, compressed air and vacuum systems, and general structural condition (ceiling, walls, flooring). Photograph any damage found.\n\nWhy: A documented checklist catches equipment or infrastructure damage that would compromise infection control or patient safety if care resumed without it.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Complete the interior damage checklist",
          "why": "A documented checklist catches equipment or infrastructure damage that would compromise infection control or patient safety if care resumed without it."
        },
        {
          "detail": "Document: Photographs and written description of each damaged item or area, with date and time, for the insurance claim.\n\nRecord: Photographs and written description of each damaged item or area, with date and time, for the insurance claim.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Document damage with photos and notes for insurance"
        },
        {
          "detail": "Confirm the practice management system, phones, and internet are functioning; check backup power or data continuity if there was an outage.\n\nWhy: A practice cannot safely resume scheduling or billing on a system that lost power mid-transaction without verifying data integrity first.",
          "id": "s5",
          "kind": "step",
          "role": "it-vendor",
          "title": "Verify systems and data integrity",
          "why": "A practice cannot safely resume scheduling or billing on a system that lost power mid-transaction without verifying data integrity first."
        },
        {
          "detail": "Is the office ready to reopen for patient care",
          "forks": [
            {
              "goto": "s12",
              "id": "not-ready",
              "label": "Damage or system issues remain unresolved — stay closed and continue repairs"
            },
            {
              "advised": true,
              "goto": "s7",
              "id": "ready",
              "label": "Checklist clear, systems verified — approve reopening"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Is the office ready to reopen for patient care"
        },
        {
          "detail": "Contact every patient whose appointment was affected by the closure with the reopening date and rebooking options. Where an AI-drafted message is used, the office reviews and edits it before sending, per AB 3030 disclosure requirements — AI-generated, reviewed by a licensed provider before it reaches a patient.\n\nWhy: Patients left without a follow-up message are the most common source of lost trust after a closure event.",
          "id": "s7",
          "kind": "step",
          "role": "scheduler",
          "title": "Notify disrupted patients with a reopening date and rebooking options",
          "why": "Patients left without a follow-up message are the most common source of lost trust after a closure event."
        },
        {
          "detail": "Unlock for patient care, confirm the front desk and clinical team are briefed on any changed procedures from the repair, and resume the schedule.\n\nWhy: A brief team briefing prevents confusion if anything (a room, a piece of equipment) is still off-limits.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Reopen and resume scheduled care",
          "why": "A brief team briefing prevents confusion if anything (a room, a piece of equipment) is still off-limits."
        },
        {
          "detail": "Document: Event date, damage found, repairs completed, insurance claim status, and reopening date, kept in the compliance/incident log.\n\nRecord: Event date, damage found, repairs completed, insurance claim status, and reopening date, kept in the compliance/incident log.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the event and recovery for the compliance record"
        },
        {
          "detail": "Recovery closed out",
          "id": "s10",
          "kind": "step",
          "role": "practice-owner",
          "title": "Recovery closed out"
        },
        {
          "detail": "Report the visible hazard (gas odor, structural damage, downed lines) to the utility company or fire department and wait for their clearance before anyone attempts to enter.\n\nWhy: Utility and structural hazards need a professional determination, not a staff guess.",
          "id": "s11",
          "kind": "step",
          "role": "office-manager",
          "title": "Call utilities and/or fire department before any re-entry",
          "why": "Utility and structural hazards need a professional determination, not a staff guess."
        },
        {
          "detail": "Address the specific items flagged, arrange contractor or vendor repair, and repeat the interior damage checklist once work is complete.\n\nWhy: Reopening on a partial fix risks a second closure and repeated patient disruption.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Continue repairs and re-run the checklist before the next reopening attempt",
          "why": "Reopening on a partial fix risks a second closure and repeated patient disruption."
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Post-disaster damage assessment, patient notification and reopening — After any evacuation or closure event, before patients are rescheduled and care resumes.",
      "title": "Post-disaster damage assessment, patient notification and reopening",
      "trigger": "After any evacuation or closure event, before patients are rescheduled and care resumes",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "DHS/CISA workplace-violence and active shooter guidance recommends rehearsed duress signals and tested alarm systems (public domain)",
          "source": "DHS/CISA workplace-violence and active shooter guidance recommends rehearsed duress signals and tested alarm systems (public domain)"
        },
        {
          "kind": "statute",
          "label": "OSHA General Duty Clause (29 U.S.C. §654) supports a documented workplace-violence prevention program",
          "source": "OSHA General Duty Clause (29 U.S.C. §654) supports a documented workplace-violence prevention program",
          "url": "https://www.osha.gov/laws-regs/oshact/section5-duties"
        }
      ],
      "class": "emergency-preparedness-plan",
      "department": "emergency",
      "duration_min": 15,
      "frequency": "monthly",
      "id": "site-015",
      "kind": "operational",
      "materials": [
        "duress code word list",
        "panic alarm button or app",
        "monitoring company contact number",
        "test log sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "office-manager",
        "all-staff",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Read the current code word (e.g., a phrase to say on the phone or to a coworker that signals a threat without alarming the person causing it) and its meaning to all staff present, and confirm new hires since the last test know it.\n\nWhy: A duress code is only useful if every staff member — including someone hired last week — can recognize and use it instinctively.",
          "id": "s1",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the current duress code words with the team",
          "why": "A duress code is only useful if every staff member — including someone hired last week — can recognize and use it instinctively."
        },
        {
          "detail": "Ask each team member privately to state the current duress code and what they would do if they heard a coworker use it, without prompting.\n\nWhy: A group recitation can mask individuals who don't actually know it; a private check catches gaps.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Quiz each staff member individually",
          "why": "A group recitation can mask individuals who don't actually know it; a private check catches gaps."
        },
        {
          "detail": "Does everyone know the current code and response",
          "forks": [
            {
              "goto": "s8",
              "id": "gap-found",
              "label": "One or more staff could not state the code or response correctly"
            },
            {
              "advised": true,
              "goto": "s4",
              "id": "all-know",
              "label": "Everyone correctly stated the code and response"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does everyone know the current code and response"
        },
        {
          "detail": "Call the alarm monitoring company to notify them a test is starting, trigger the panic alarm button or app, and confirm the monitoring company received the signal.\n\nWhy: Notifying the monitoring company first prevents an unnecessary dispatch of police to a test.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Test the panic alarm with the monitoring company",
          "why": "Notifying the monitoring company first prevents an unnecessary dispatch of police to a test."
        },
        {
          "detail": "Did the monitoring company confirm receipt of the test signal",
          "forks": [
            {
              "goto": "s9",
              "id": "failed",
              "label": "No confirmation received — alarm did not register"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "confirmed",
              "label": "Monitoring company confirmed receipt"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Did the monitoring company confirm receipt of the test signal"
        },
        {
          "detail": "Document: Date, staff quizzed and result, any retraining given, alarm test result, and monitoring company confirmation, kept in the safety test log.\n\nRecord: Date, staff quizzed and result, any retraining given, alarm test result, and monitoring company confirmation, kept in the safety test log.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the monthly test"
        },
        {
          "detail": "Monthly test complete",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Monthly test complete"
        },
        {
          "detail": "Walk the affected staff member through the code and the expected response again, then re-ask them to state it back.\n\nWhy: Closing the gap immediately, rather than at next month's test, keeps the safety net intact.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Retrain the gap and re-quiz before moving on",
          "why": "Closing the gap immediately, rather than at next month's test, keeps the safety net intact."
        },
        {
          "detail": "Report the failed test to the alarm system vendor or IT support for troubleshooting and schedule a repeat test once fixed; do not consider the panic alarm reliable until confirmed.",
          "id": "s9",
          "kind": "step",
          "role": "it-vendor",
          "title": "Hand off to the alarm vendor for repair"
        }
      ],
      "subclass": "site-emergencies-disasters-and-public-health",
      "summary": "Duress code words and panic-alarm monthly test — The first week of each month, or a new team member has not learned the codes.",
      "title": "Duress code words and panic-alarm monthly test",
      "trigger": "The first week of each month, or a new team member has not learned the codes",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3.1-3.2 (in-repo pre-injection assessment and maximum-dose table)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3.1-3.2 (in-repo pre-injection assessment and maximum-dose table)"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "sla-001",
      "kind": "clinical",
      "materials": [
        "updated medical history form",
        "weight (kg) for pediatric or low-weight patients",
        "anesthetic cartridge log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm allergies (especially amide vs. ester local anesthetics), current medications (MAOIs, beta-blockers, anticoagulants, bisphosphonates), bleeding disorders and cardiovascular history are current for today's visit.\n\nWhy: An allergy or drug interaction missed here is the leading preventable cause of an anesthetic adverse event.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Review updated medical history before any injection",
          "why": "An allergy or drug interaction missed here is the leading preventable cause of an anesthetic adverse event."
        },
        {
          "detail": "Any new medical-history flag since the last visit?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "none",
              "label": "No new flags"
            },
            {
              "goto": "s11",
              "id": "flag",
              "label": "New flag present (allergy, new medication, cardiac event)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Any new medical-history flag since the last visit?"
        },
        {
          "detail": "Is the patient hypertensive, cardiac, or notably anxious?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "yes",
              "label": "Yes — take blood pressure before injecting"
            },
            {
              "goto": "s5",
              "id": "no",
              "label": "No indication for pre-injection BP"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the patient hypertensive, cardiac, or notably anxious?"
        },
        {
          "detail": "Record systolic/diastolic; flag to the dentist if outside the practice's treat/defer thresholds before any anesthetic is given.\n\nRecord: Pre-injection blood pressure reading",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Take and record blood pressure before injecting"
        },
        {
          "detail": "For pediatric or low-weight adult patients, calculate maximum dose by kg using the practice's published agent table (e.g. lidocaine 2% with epi 4.4 mg/kg, max 300mg — per DOCS/TECHNICAL_PROTOCOLS.md §3.2, consistent with the ADA sedation/anesthesia guideline cited in public_domain_basis). These are practice-configurable defaults, not fixed constants: before the table is relied on for a given agent, the dentist confirms the mg/kg and max-mg figures against that agent's current FDA-approved package insert. Convert to a maximum cartridge count before the first injection.\n\nWhy: Calculating a cartridge ceiling before starting prevents dose creep across multiple injections in one visit.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Calculate the weight-based maximum recommended dose",
          "why": "Calculating a cartridge ceiling before starting prevents dose creep across multiple injections in one visit."
        },
        {
          "detail": "Write down agent, vasoconstrictor, cartridge count and injection site as each cartridge is given.\n\nRecord: Anesthetic agent, vasoconstrictor concentration, cartridge count, injection site(s), and running total against the calculated maximum",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Log agent, dose, site and cartridge count as each is given"
        },
        {
          "detail": "If the running cartridge total approaches the calculated maximum, the assistant stops and the treating dentist confirms whether an additional cartridge is safe before it is given.\n\nWhy: The dose ceiling exists to prevent local anesthetic systemic toxicity; a running count without a stop point does not protect the patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Stop and confirm with the dentist before approaching the calculated maximum.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Stop and confirm with the dentist before approaching the calculated maximum",
          "why": "The dose ceiling exists to prevent local anesthetic systemic toxicity; a running count without a stop point does not protect the patient."
        },
        {
          "detail": "Re-run this check before every additional cartridge, not only once at the end of the visit.",
          "forks": [
            {
              "goto": "s6",
              "id": "more-needed",
              "label": "Yes — another cartridge is needed; log it and re-run the max-dose gate"
            },
            {
              "advised": true,
              "goto": "s9",
              "id": "visit-complete",
              "label": "No — this visit's injections are complete"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "dentist",
          "title": "Are more cartridges needed to complete today's anesthesia for this visit?"
        },
        {
          "detail": "Enter total cartridges used against the calculated maximum into the practice's tracking sheet.\n\nRecord: Total cartridges used vs. calculated maximum for the encounter",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the visit's dose-tracking metric"
        },
        {
          "detail": "Pre-anesthetic assessment and dose tracking complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Pre-anesthetic assessment and dose tracking complete"
        },
        {
          "detail": "The treating dentist personally reviews the new history item and decides whether to adjust agent choice, vasoconstrictor, or defer treatment for a medical consult.\n\nWhy: A history flag changes which agent and dose are safe; a non-clinical staff member cannot make this call.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews the flag before proceeding",
          "why": "A history flag changes which agent and dose are safe; a non-clinical staff member cannot make this call."
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Pre-anesthetic assessment, weight-based maximum dose calculation and cartridge tracking — Any local anesthetic is about to be administered — cartridges counted against the maximum dose, type, amount and site recorded.",
      "title": "Pre-anesthetic assessment, weight-based maximum dose calculation and cartridge tracking",
      "trigger": "Any local anesthetic is about to be administered — cartridges counted against the maximum dose, type, amount and site recorded",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3.3 (in-repo injection technique)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3.3 (in-repo injection technique)"
        },
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "sla-002",
      "kind": "clinical",
      "materials": [
        "topical anesthetic gel",
        "cotton-tip applicator",
        "anesthetic cartridge and syringe",
        "aspirating syringe"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Apply topical gel to dried mucosa at the planned needle entry point and hold for 1–2 minutes before the injection.\n\nWhy: Topical anesthesia reduces the discomfort of needle penetration and improves patient cooperation.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Apply topical anesthesia at the injection site",
          "why": "Topical anesthesia reduces the discomfort of needle penetration and improves patient cooperation."
        },
        {
          "detail": "Advance to the planned depth for the technique being used (infiltration or block) with a controlled, slow approach.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Position the needle at the target site"
        },
        {
          "detail": "Draw back on the syringe and check the cartridge for blood before depositing. This is mandatory before every deposition, not only the first.\n\nWhy: A positive aspiration means the needle tip is in a vessel; depositing there risks intravascular injection and systemic toxicity.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Aspirate before depositing any anesthetic",
          "why": "A positive aspiration means the needle tip is in a vessel; depositing there risks intravascular injection and systemic toxicity."
        },
        {
          "detail": "Is the aspiration positive (blood visible in the cartridge)?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "negative",
              "label": "Negative — proceed to slow deposition"
            },
            {
              "goto": "s10",
              "id": "positive",
              "label": "Positive — withdraw and reposition"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the aspiration positive (blood visible in the cartridge)?"
        },
        {
          "detail": "The treating dentist confirms the aspiration was negative and it is safe to deposit before continuing.\n\nWhy: A positive aspiration deposited anyway risks intravascular injection; the confirming step is the last check before that happens.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms negative aspiration before deposition.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms negative aspiration before deposition",
          "why": "A positive aspiration deposited anyway risks intravascular injection; the confirming step is the last check before that happens."
        },
        {
          "detail": "Deposit the anesthetic at a slow, steady rate; do not bolus.\n\nWhy: Slow deposition reduces both the risk of systemic toxicity and injection discomfort.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Deposit slowly — approximately 1ml per minute",
          "why": "Slow deposition reduces both the risk of systemic toxicity and injection discomfort."
        },
        {
          "detail": "Observe for signs of an adverse reaction (pallor, tachycardia complaint, dizziness, perioral tingling) throughout the injection.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Watch the patient's response during and immediately after deposition"
        },
        {
          "detail": "Write the agent, dose, injection site, aspiration result and patient response into the chart note.\n\nRecord: Anesthetic agent, dose, injection site, aspiration result, and patient response in the chart",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document agent, dose, site, aspiration result and patient response"
        },
        {
          "detail": "Injection technique complete and documented",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Injection technique complete and documented"
        },
        {
          "detail": "Withdraw slightly, redirect, and aspirate again before depositing.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Withdraw and reposition the needle"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Topical anesthesia, aspiration and slow-injection technique — An infiltration or block is being given.",
      "title": "Topical anesthesia, aspiration and slow-injection technique",
      "trigger": "An infiltration or block is being given",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3.3 (in-repo IANB success rate and supplement guidance)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3.3 (in-repo IANB success rate and supplement guidance)"
        },
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 8,
      "frequency": "per-use",
      "id": "sla-003",
      "kind": "clinical",
      "materials": [
        "long dental needle",
        "anesthetic cartridges",
        "long buccal supplemental agent"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Locate landmarks and advance the needle to target the inferior alveolar nerve at the pterygomandibular space, per standard IANB landmark technique.\n\nWhy: The pterygomandibular space is the standard target for anesthetizing the inferior alveolar nerve trunk.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Target the pterygomandibular space",
          "why": "The pterygomandibular space is the standard target for anesthetizing the inferior alveolar nerve trunk."
        },
        {
          "detail": "Draw back on the syringe and check the cartridge for blood before depositing, per sla-002 technique. The IANB's proximity to the inferior alveolar vessels and pterygoid venous plexus makes a positive-aspiration check especially critical at this site.\n\nWhy: A positive aspiration means the needle tip is in a vessel; depositing there risks intravascular injection and systemic toxicity.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Aspirate before depositing any anesthetic",
          "why": "A positive aspiration means the needle tip is in a vessel; depositing there risks intravascular injection and systemic toxicity."
        },
        {
          "detail": "Is the aspiration positive (blood visible in the cartridge)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "negative",
              "label": "Negative — proceed to slow deposition"
            },
            {
              "goto": "s11",
              "id": "positive",
              "label": "Positive — withdraw and reposition"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the aspiration positive (blood visible in the cartridge)?"
        },
        {
          "detail": "The treating dentist confirms the aspiration was negative and it is safe to deposit before continuing.\n\nWhy: A positive aspiration deposited anyway risks intravascular injection; the confirming step is the last check before that happens.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms negative aspiration before deposition.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms negative aspiration before deposition",
          "why": "A positive aspiration deposited anyway risks intravascular injection; the confirming step is the last check before that happens."
        },
        {
          "detail": "Deposit the full cartridge slowly and steadily at the target site; do not bolus.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Deposit slowly — approximately 1ml per minute"
        },
        {
          "detail": "Allow several minutes for onset before checking lip numbness and testing the tooth.",
          "id": "s6",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 300,
          "title": "Wait for onset before testing anesthesia"
        },
        {
          "detail": "Is profound anesthesia confirmed (lip numb, no response to testing)?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "Profound anesthesia confirmed"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "Block failed or incomplete"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Is profound anesthesia confirmed (lip numb, no response to testing)?"
        },
        {
          "detail": "The treating dentist personally confirms lip numbness and no response to testing before proceeding with treatment.\n\nWhy: Starting an invasive procedure on anesthesia that only seems adequate risks intra-operative pain and a compromised outcome.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms profound anesthesia before starting the procedure.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms profound anesthesia before starting the procedure",
          "why": "Starting an invasive procedure on anesthesia that only seems adequate risks intra-operative pain and a compromised outcome."
        },
        {
          "detail": "Record the block technique used, any supplements given, and confirmation of profound anesthesia.\n\nRecord: Block technique, supplements if any, and confirmed anesthesia status",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Document confirmed anesthesia"
        },
        {
          "detail": "Inferior alveolar block sequence complete",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Inferior alveolar block sequence complete"
        },
        {
          "detail": "Withdraw slightly, redirect toward the pterygomandibular space, and aspirate again before depositing.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Withdraw and reposition the needle"
        },
        {
          "detail": "Choose a supplemental technique",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "long-buccal",
              "label": "Supplement with long buccal infiltration"
            },
            {
              "goto": "s1",
              "id": "repeat-block",
              "label": "Repeat the block attempt with adjusted landmark"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "dentist",
          "title": "Choose a supplemental technique"
        },
        {
          "detail": "Administer the chosen supplemental technique (e.g. long buccal, intraligamentary, or intraosseous per practice-stocked materials) following the same aspiration and slow-deposit technique.",
          "id": "s13",
          "kind": "step",
          "role": "dentist",
          "title": "Give the supplemental injection"
        },
        {
          "detail": "Allow onset time before re-testing.",
          "id": "s14",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 180,
          "title": "Wait for supplemental onset"
        },
        {
          "detail": "Is anesthesia now profound?",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "yes",
              "label": "Yes — proceed"
            },
            {
              "goto": "s16",
              "id": "no",
              "label": "Still not profound — defer or escalate anesthesia strategy"
            }
          ],
          "id": "s15",
          "kind": "fork",
          "role": "dentist",
          "title": "Is anesthesia now profound?"
        },
        {
          "detail": "If repeated attempts and supplementation fail, defer to sla-004 (anesthesia-for-hot-tooth-irreversible-pulpitis) or reschedule with an alternate plan.",
          "id": "s16",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to the hot-tooth anesthesia strategy protocol"
        },
        {
          "detail": "Record which block attempts and supplemental techniques were tried, current anesthesia status, and the plan.\n\nRecord: Block attempts, supplemental techniques tried, anesthesia status, and the plan (reschedule or alternate strategy)",
          "id": "s17",
          "kind": "step",
          "role": "dentist",
          "title": "Document the failed attempts and next step"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Inferior alveolar nerve block with supplemental techniques for failure — Mandibular posterior anesthesia is needed or the block failed.",
      "title": "Inferior alveolar nerve block with supplemental techniques for failure",
      "trigger": "Mandibular posterior anesthesia is needed or the block failed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3.3 (in-repo IANB success rate baseline)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3.3 (in-repo IANB success rate baseline)"
        },
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "sla-004",
      "kind": "clinical",
      "materials": [
        "additional anesthetic cartridges",
        "intraosseous or intraligamentary injection kit if stocked",
        "buffered-anesthetic option if stocked"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm symptomatic history (lingering pain to hot/cold, spontaneous pain) and that a standard IANB has already been attempted without profound anesthesia.\n\nWhy: Inflamed pulp tissue is harder to anesthetize; a hot tooth needs an escalation strategy, not a repeat of the same technique.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the working diagnosis is irreversible pulpitis on a mandibular molar",
          "why": "Inflamed pulp tissue is harder to anesthetize; a hot tooth needs an escalation strategy, not a repeat of the same technique."
        },
        {
          "detail": "Was the original block technique and landmark correct?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "repeat-correct",
              "label": "Technique was correct — escalate to supplemental methods"
            },
            {
              "goto": "s10",
              "id": "retry-block",
              "label": "Retry the block with adjusted landmark first"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Was the original block technique and landmark correct?"
        },
        {
          "detail": "Options in typical escalation order: long buccal + supplemental infiltration, intraligamentary injection, intraosseous injection, buffered anesthetic if stocked, or pulpal (intrapulpal) anesthesia once the pulp chamber is exposed.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Escalation options for the hot tooth"
        },
        {
          "detail": "Give the selected supplemental or alternate technique following aspiration and slow-deposit practice per sla-002.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Administer the chosen escalation technique"
        },
        {
          "detail": "Allow onset time, then test the tooth for a response before starting the procedure.",
          "id": "s5",
          "kind": "timer",
          "role": "dentist",
          "timer_seconds": 300,
          "title": "Wait for onset and re-test"
        },
        {
          "detail": "Is anesthesia now adequate to proceed?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes",
              "label": "Adequate — proceed"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "Still inadequate — reschedule with alternate plan"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "dentist",
          "title": "Is anesthesia now adequate to proceed?"
        },
        {
          "detail": "The treating dentist confirms the tooth is adequately anesthetized before starting or continuing treatment.\n\nWhy: A hot tooth that seems numb but is not will cause the patient significant pain once treatment starts.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms adequate anesthesia before proceeding.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms adequate anesthesia before proceeding",
          "why": "A hot tooth that seems numb but is not will cause the patient significant pain once treatment starts."
        },
        {
          "detail": "Record the escalation techniques attempted in order, the outcome, and the plan if deferred.\n\nRecord: Techniques attempted in order, outcome, and next step if deferred",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document the escalation path and outcome"
        },
        {
          "detail": "Hot-tooth anesthesia strategy complete",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hot-tooth anesthesia strategy complete"
        },
        {
          "detail": "Redirect and repeat per sla-003 technique.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Retry the inferior alveolar block with adjusted approach"
        },
        {
          "detail": "Profound anesthesia now?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "yes",
              "label": "Yes — proceed with treatment"
            },
            {
              "goto": "s3",
              "id": "no",
              "label": "No — escalate to supplemental methods"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Profound anesthesia now?"
        },
        {
          "detail": "Front desk reschedules the patient with a note to plan for an alternate technique or specialist referral on the next attempt.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to scheduling for a revised anesthesia plan visit"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Anesthesia strategy for the hot tooth (irreversible pulpitis) — Profound anesthesia is not achieved on a symptomatic mandibular molar.",
      "title": "Anesthesia strategy for the hot tooth (irreversible pulpitis)",
      "trigger": "Profound anesthesia is not achieved on a symptomatic mandibular molar",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Dental Board of California sedation permits (B&P §1646–1647)",
          "source": "Dental Board of California sedation permits (B&P §1646–1647)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3 (in-repo anesthesia technique baseline)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3 (in-repo anesthesia technique baseline)"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "sla-005",
      "kind": "clinical",
      "materials": [
        "hygienist local-anesthesia permit/certification record",
        "supervision log",
        "anesthetic cartridges"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "hygienist",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Before any delegated injection, confirm the hygienist's state permit or certification for local anesthesia administration is current and on file.\n\nWhy: Administering anesthesia outside a valid permit is a scope-of-practice violation that exposes both the hygienist and the practice.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Verify the hygienist holds a current local-anesthesia permit/certification.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Verify the hygienist holds a current local-anesthesia permit/certification",
          "why": "Administering anesthesia outside a valid permit is a scope-of-practice violation that exposes both the hygienist and the practice."
        },
        {
          "detail": "Does state scope require the dentist to be on-site (direct supervision) for this procedure?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "direct",
              "label": "Direct supervision required — dentist confirms presence in the office"
            },
            {
              "goto": "s4",
              "id": "general",
              "label": "General supervision permitted — dentist has authorized the treatment plan"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Does state scope require the dentist to be on-site (direct supervision) for this procedure?"
        },
        {
          "detail": "The dentist confirms they are present in the office before the hygienist proceeds, per the practice's direct-supervision requirement.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms on-site presence before injection.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms on-site presence before injection"
        },
        {
          "detail": "Confirm the treatment plan authorizes anesthesia for today's SRP quadrant(s) and that the medical history has been reviewed per sla-001.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist reviews medical history and treatment plan"
        },
        {
          "detail": "Apply topical anesthesia, position the needle at the target site, and aspirate before depositing any anesthetic, following the technique in sla-002.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Apply topical, position the needle, and aspirate before depositing"
        },
        {
          "detail": "Is the aspiration positive (blood visible in the cartridge)?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "negative",
              "label": "Negative — proceed to slow deposition"
            },
            {
              "goto": "s11",
              "id": "positive",
              "label": "Positive — withdraw and reposition"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "hygienist",
          "title": "Is the aspiration positive (blood visible in the cartridge)?"
        },
        {
          "detail": "The administering hygienist confirms the aspiration was negative and it is safe to deposit before continuing.\n\nWhy: A positive aspiration deposited anyway risks intravascular injection; this consequential step stays gated inside this protocol's own graph rather than only by cross-document convention.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Administering hygienist confirms negative aspiration before deposition.",
            "role": "hygienist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "hygienist",
          "title": "Administering hygienist confirms negative aspiration before deposition",
          "why": "A positive aspiration deposited anyway risks intravascular injection; this consequential step stays gated inside this protocol's own graph rather than only by cross-document convention."
        },
        {
          "detail": "Deposit the anesthetic at a slow, steady rate; do not bolus.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Deposit slowly — approximately 1ml per minute"
        },
        {
          "detail": "Record agent, dose, site, aspiration result, hygienist and supervising dentist names, and supervision model.\n\nRecord: Agent, dose, site, aspiration result, hygienist name, supervising dentist name, and supervision model (direct/general)",
          "id": "s9",
          "kind": "step",
          "role": "hygienist",
          "title": "Document the anesthesia and supervision model used"
        },
        {
          "detail": "Hygienist-administered anesthesia complete and documented",
          "id": "s10",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist-administered anesthesia complete and documented"
        },
        {
          "detail": "Withdraw slightly, redirect, and aspirate again before depositing.",
          "id": "s11",
          "kind": "step",
          "role": "hygienist",
          "title": "Withdraw and reposition the needle"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Hygienist-administered local anesthesia — scope, supervision, documentation — A hygienist will anesthetize for SRP under state-permitted scope.",
      "title": "Hygienist-administered local anesthesia — scope, supervision, documentation",
      "trigger": "A hygienist will anesthetize for SRP under state-permitted scope",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §6.1 (in-repo nitrous oxide sedation note)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §6.1 (in-repo nitrous oxide sedation note)"
        },
        {
          "kind": "public_domain",
          "label": "NIOSH nitrous oxide exposure control guidance",
          "source": "NIOSH nitrous oxide exposure control guidance",
          "url": "https://www.cdc.gov/niosh/docs/94-129/default.html"
        },
        {
          "kind": "regulation",
          "label": "No Cal/OSHA or federal regulation specifically mandates dental nitrous-oxide scavenging equipment, fail-safe valve testing, or titration/recovery procedure; Title 8 CCR §5155 (Airborne Contaminants) sets a general permissible exposure limit for nitrous oxide (50 ppm 8-hr TWA) that bears only on the staff-exposure-monitoring slice of sla-006/sla-013, not on scavenging equipment, fail-safe testing, or titration/recovery — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No Cal/OSHA or federal regulation specifically mandates dental nitrous-oxide scavenging equipment, fail-safe valve testing, or titration/recovery procedure; Title 8 CCR §5155 (Airborne Contaminants) sets a general permissible exposure limit for nitrous oxide (50 ppm 8-hr TWA) that bears only on the staff-exposure-monitoring slice of sla-006/sla-013, not on scavenging equipment, fail-safe testing, or titration/recovery — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Independently searched for a CA-specific nitrous-oxide scavenging/dental-operatory regulation and found none; Cal/OSHA has no dedicated standard for N2O scavenging equipment. The closest real, verifiable authority is Title 8 CCR §5155 (dir.ca.gov/title8/5155.html), which sets the airborne-contaminant PEL (50 ppm TWA) — a general workplace-exposure ceiling, not an equipment, fail-safe-test, or titration/recovery requirement. §5142 (the round-one source, confirmed again by direct read) is HVAC minimum outdoor-air ventilation and never mentions nitrous oxide.",
            "ticket": "PROT-017",
            "was": {
              "source": "Cal/OSHA (DOSH) Title 8 CCR §5142 — Mechanically Driven Heating, Ventilating and Air Conditioning (HVAC) Systems to Provide Minimum Building Ventilation",
              "url": "https://www.dir.ca.gov/title8/5142.html"
            }
          },
          "source": "No Cal/OSHA or federal regulation specifically mandates dental nitrous-oxide scavenging equipment, fail-safe valve testing, or titration/recovery procedure; Title 8 CCR §5155 (Airborne Contaminants) sets a general permissible exposure limit for nitrous oxide (50 ppm 8-hr TWA) that bears only on the staff-exposure-monitoring slice of sla-006/sla-013, not on scavenging equipment, fail-safe testing, or titration/recovery — Practice policy — no published authority governs this step."
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "sla-006",
      "kind": "clinical",
      "materials": [
        "nitrous oxide/oxygen delivery unit with scavenging system",
        "nasal hood, correctly sized",
        "flowmeter"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the patient (or caregiver for a minor) has signed consent specific to nitrous oxide sedation before the mask is placed.\n\nWhy: Sedation, even minimal, requires its own consent distinct from the procedure consent.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm informed consent for nitrous oxide sedation.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Confirm informed consent for nitrous oxide sedation",
          "why": "Sedation, even minimal, requires its own consent distinct from the procedure consent."
        },
        {
          "detail": "Confirm the updated medical history (per sla-001) has been reviewed for nitrous-specific contraindications — first-trimester pregnancy, COPD/CO2 retention, current nasal or upper-airway obstruction, or recent middle-ear/sinus surgery — before equipment is set up.\n\nWhy: Nitrous oxide carries contraindications distinct from the local-anesthesia history review; confirming them before setup avoids placing the mask on a patient for whom nitrous is not appropriate.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the medical history has been reviewed for nitrous-specific contraindications",
          "why": "Nitrous oxide carries contraindications distinct from the local-anesthesia history review; confirming them before setup avoids placing the mask on a patient for whom nitrous is not appropriate."
        },
        {
          "detail": "Confirm the fail-safe oxygen system, flowmeter, nasal hood fit, and scavenging exhaust are functioning per the daily equipment check (sla-013) before use.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm nitrous equipment and scavenging system are functional"
        },
        {
          "detail": "Select a correctly sized nasal hood and fit it comfortably to the patient's face, confirming a good seal for the scavenging system.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Place and fit the nasal hood"
        },
        {
          "detail": "Start the flow at 100% oxygen for one to two minutes before introducing nitrous.\n\nWhy: Baselining on 100% oxygen lets the patient acclimate to the mask and gives a clean starting point for titration.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Begin with 100% oxygen",
          "why": "Baselining on 100% oxygen lets the patient acclimate to the mask and gives a clean starting point for titration."
        },
        {
          "detail": "Increase nitrous percentage in small steps (e.g. 10% increments), pausing between each to assess the patient's response, until the desired level of comfort is reached.\n\nWhy: Titrating slowly avoids overshoot into deeper sedation than intended for a minimal-sedation nitrous case.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Titrate nitrous oxide in small increments",
          "why": "Titrating slowly avoids overshoot into deeper sedation than intended for a minimal-sedation nitrous case."
        },
        {
          "detail": "Confirm the patient remains verbally responsive and comfortable throughout; adjust nitrous percentage as needed.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Monitor the patient's responsiveness throughout the procedure"
        },
        {
          "detail": "Reduce nitrous to 0% and deliver 100% oxygen for a minimum recovery period before removing the nasal hood.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Return to 100% oxygen at the end of the procedure"
        },
        {
          "detail": "Wait through the full oxygen recovery period before assessing the patient for discharge readiness.\n\nWhy: A recovery period on 100% oxygen clears residual nitrous and prevents post-sedation dizziness ('diffusion hypoxia').",
          "id": "s9",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 300,
          "title": "100% oxygen recovery period",
          "why": "A recovery period on 100% oxygen clears residual nitrous and prevents post-sedation dizziness ('diffusion hypoxia')."
        },
        {
          "detail": "Is the patient alert and oriented after the recovery period?",
          "forks": [
            {
              "advised": true,
              "goto": "s11",
              "id": "yes",
              "label": "Alert and oriented — clear for discharge"
            },
            {
              "goto": "s9",
              "id": "no",
              "label": "Not yet recovered — extend recovery time"
            }
          ],
          "id": "s10",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the patient alert and oriented after the recovery period?"
        },
        {
          "detail": "Record nitrous percentage(s) used, duration, patient response, and recovery time before discharge.\n\nRecord: Nitrous percentage(s) used, duration, patient response during titration, and recovery time before discharge",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Document titration, monitoring and recovery"
        },
        {
          "detail": "Nitrous oxide sedation complete and patient recovered",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Nitrous oxide sedation complete and patient recovered"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Nitrous oxide/oxygen minimal sedation — titration, monitoring, recovery, scavenging — An anxious adult patient consented to nitrous oxide.",
      "title": "Nitrous oxide/oxygen minimal sedation — titration, monitoring, recovery, scavenging",
      "trigger": "An anxious adult patient consented to nitrous oxide",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Dental Board of California sedation permits (B&P §1646–1647)",
          "source": "Dental Board of California sedation permits (B&P §1646–1647)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        },
        {
          "kind": "open_standard",
          "label": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "source": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "url": "https://pediatrics.aappublications.org/content/143/6/e20191000"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "per-use",
      "id": "sla-007",
      "kind": "clinical",
      "materials": [
        "dentist's current sedation permit on file",
        "pulse oximeter",
        "pre-op instruction sheet (fasting, escort)",
        "emergency drug kit"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm the treating dentist's state sedation permit is current and covers the sedation level (minimal/moderate) planned for this patient before scheduling proceeds.\n\nWhy: Sedating beyond a permit's authorized level is a licensing violation independent of clinical outcome.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Verify the dentist's sedation permit is current for the planned level of sedation.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Verify the dentist's sedation permit is current for the planned level of sedation",
          "why": "Sedating beyond a permit's authorized level is a licensing violation independent of clinical outcome."
        },
        {
          "detail": "Provide written fasting instructions (per the sedative used) and confirm the patient must arrange a responsible adult escort for the day of the appointment.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Give pre-op fasting and escort instructions in advance"
        },
        {
          "detail": "Confirm: fasting status per instructions, escort physically present and identified, medical history unchanged, baseline vitals taken.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Day-of verification before any sedative is given"
        },
        {
          "detail": "The dentist confirms the escort's identity and understanding of their responsibility to remain and transport the patient home before the first dose is given.\n\nWhy: A sedated patient cannot be discharged to drive themselves or leave unaccompanied; this must be confirmed before, not after, sedation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Confirm a responsible escort is present before administering the sedative.",
            "type": "safety"
          },
          "id": "s4",
          "kind": "gate",
          "role": "caregiver",
          "title": "Confirm a responsible escort is present before administering the sedative",
          "why": "A sedated patient cannot be discharged to drive themselves or leave unaccompanied; this must be confirmed before, not after, sedation."
        },
        {
          "detail": "Was the fasting instruction followed?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes",
              "label": "Fasting confirmed — proceed"
            },
            {
              "goto": "s12",
              "id": "no",
              "label": "Fasting not followed — reschedule"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Was the fasting instruction followed?"
        },
        {
          "detail": "The treating dentist calculates the sedative dose against the drug's published maximum for the patient's weight and age, records the calculated dose in the chart, and confirms it is within range before the dose is given.\n\nWhy: Sedation dosing error is a leading preventable cause of pediatric and adult sedation morbidity; a recorded dose calculation before administration is the last check that catches it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms and records the weight/age-based sedative dose before administration.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms and records the weight/age-based sedative dose before administration",
          "why": "Sedation dosing error is a leading preventable cause of pediatric and adult sedation morbidity; a recorded dose calculation before administration is the last check that catches it."
        },
        {
          "detail": "Give the sedative dose ordered by the treating dentist, consistent with the permit level.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Administer the sedative per the dentist's order"
        },
        {
          "detail": "Assistant takes over continuous vitals monitoring per sla-008 for the duration of the sedation.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off to sedation monitoring protocol"
        },
        {
          "detail": "At procedure end, hand off to sla-009 for discharge criteria, escort verification and written post-op instructions.",
          "id": "s9",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off to discharge criteria protocol"
        },
        {
          "detail": "Record permit verification, fasting and escort confirmation, sedative and dose given, with links to monitoring and discharge records.\n\nRecord: Permit verification, fasting/escort confirmation, sedative and dose, and reference to the monitoring and discharge records",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Document the sedation encounter"
        },
        {
          "detail": "Oral sedation encounter complete",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Oral sedation encounter complete"
        },
        {
          "detail": "Front desk reschedules the sedation appointment and reissues fasting/escort instructions.",
          "id": "s12",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to scheduling to reschedule"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Oral minimal or moderate sedation — permit, pre-op fasting, escort, monitoring, discharge criteria — A patient is scheduled for oral sedation under the dentist's permit.",
      "title": "Oral minimal or moderate sedation — permit, pre-op fasting, escort, monitoring, discharge criteria",
      "trigger": "A patient is scheduled for oral sedation under the dentist's permit",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "source": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "url": "https://pediatrics.aappublications.org/content/143/6/e20191000"
        },
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        },
        {
          "kind": "statute",
          "label": "Dental Board of California sedation permits (B&P §1646–1647)",
          "source": "Dental Board of California sedation permits (B&P §1646–1647)",
          "url": "https://www.dbc.ca.gov/"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "per-use",
      "id": "sla-008",
      "kind": "clinical",
      "materials": [
        "pulse oximeter",
        "capnography monitor if required by permit level",
        "blood pressure cuff",
        "time-based monitoring log sheet"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Designate a team member whose sole task during the procedure is watching the patient's vitals and level of consciousness — not also assisting chairside.\n\nWhy: A monitor with a second job cannot reliably catch a developing complication in time.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Assign a dedicated monitor for the duration of sedation",
          "why": "A monitor with a second job cannot reliably catch a developing complication in time."
        },
        {
          "detail": "Record baseline pulse oximetry, blood pressure and heart rate before any sedative dose.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Record baseline vitals before the sedative is given"
        },
        {
          "detail": "Attach continuous pulse oximetry for all sedation; add capnography if the permit level or patient risk requires it.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Attach pulse oximeter and capnography if required"
        },
        {
          "detail": "Record oxygen saturation, heart rate, and level of consciousness at the practice's set monitoring interval on a time-based log until recovery is complete.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Record vitals at fixed intervals throughout the procedure"
        },
        {
          "detail": "Is any vital outside the safe range or does the monitor alarm?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "normal",
              "label": "Vitals within range"
            },
            {
              "goto": "s7",
              "id": "abnormal",
              "label": "Vital out of range or alarm triggered"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Is any vital outside the safe range or does the monitor alarm?"
        },
        {
          "detail": "Is the procedure still underway?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "continue",
              "label": "Still underway — continue interval monitoring"
            },
            {
              "goto": "s8",
              "id": "done",
              "label": "Procedure complete — hand off to discharge criteria"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the procedure still underway?"
        },
        {
          "detail": "Immediately notify the dentist; if the patient does not stabilize with basic airway/oxygen measures, call 911 and begin the office's medical emergency response.\n\nWhy: An unstable sedated patient is a life-threatening emergency; monitoring exists specifically to catch this early enough to act.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 / activate the office medical emergency response if the patient is not stabilizing.",
            "type": "safety"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Call 911 / activate the office medical emergency response if the patient is not stabilizing",
          "why": "An unstable sedated patient is a life-threatening emergency; monitoring exists specifically to catch this early enough to act."
        },
        {
          "detail": "Provide the full time-based monitoring log to the dentist for the discharge decision under sla-009.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Hand off the completed monitoring record to discharge"
        },
        {
          "detail": "The treating dentist reviews the full time-based vitals record and signs it before it is filed as complete.\n\nWhy: The monitoring record supports the discharge decision; a licensed sign-off confirms it was reviewed, not just collected.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist reviews and signs the completed monitoring record.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist reviews and signs the completed monitoring record",
          "why": "The monitoring record supports the discharge decision; a licensed sign-off confirms it was reviewed, not just collected."
        },
        {
          "detail": "Finalize the interval-by-interval vitals log with any out-of-range events and the response taken.\n\nRecord: Complete interval-by-interval vitals log, any out-of-range events and the response taken",
          "id": "s10",
          "kind": "step",
          "role": "assistant",
          "title": "Finalize the time-based monitoring record"
        },
        {
          "detail": "Sedation monitoring record complete",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Sedation monitoring record complete"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Sedation monitoring — vitals interval, oximetry, capnography where required, time-based record — Any sedation beyond nitrous oxide is underway.",
      "title": "Sedation monitoring — vitals interval, oximetry, capnography where required, time-based record",
      "trigger": "Any sedation beyond nitrous oxide is underway",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        },
        {
          "kind": "open_standard",
          "label": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "source": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "url": "https://pediatrics.aappublications.org/content/143/6/e20191000"
        },
        {
          "kind": "statute",
          "label": "Dental Board of California sedation permits (B&P §1646–1647)",
          "source": "Dental Board of California sedation permits (B&P §1646–1647)",
          "url": "https://www.dbc.ca.gov/"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "sla-009",
      "kind": "clinical",
      "materials": [
        "discharge criteria checklist",
        "vitals monitor",
        "written post-op instruction sheet",
        "escort sign-out log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "assistant",
        "caregiver",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Confirm vitals are back to baseline, the patient is alert and oriented, ambulates with minimal assistance, and protective reflexes have returned before ending monitoring.\n\nWhy: Per the ADA sedation guideline, discharge is decided against objective criteria, not elapsed time alone.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the patient meets objective discharge criteria",
          "why": "Per the ADA sedation guideline, discharge is decided against objective criteria, not elapsed time alone."
        },
        {
          "detail": "Compare the patient's current status against the practice's discharge checklist.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "criteria-met",
              "label": "Criteria met — proceed to discharge"
            },
            {
              "goto": "s11",
              "id": "criteria-not-met",
              "label": "Not yet met — continue monitoring"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Are discharge criteria met?"
        },
        {
          "detail": "The treating dentist personally reviews the vitals and status and signs off that the patient is fit for discharge — this cannot be delegated.\n\nWhy: Discharge fitness after sedation is a clinical judgment carrying real risk if wrong; it stays with the licensed provider.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating dentist signs off on fitness for discharge.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating dentist signs off on fitness for discharge",
          "why": "Discharge fitness after sedation is a clinical judgment carrying real risk if wrong; it stays with the licensed provider."
        },
        {
          "detail": "Confirm a responsible adult escort is physically present, identify them by name and relationship, and confirm they can supervise the patient for the remainder of the day.\n\nWhy: A patient recovering from sedation cannot reliably assess their own fitness to drive or be alone.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Verify a responsible adult escort is present",
          "why": "A patient recovering from sedation cannot reliably assess their own fitness to drive or be alone."
        },
        {
          "detail": "If no escort is present, hold the patient in the office, contact the emergency contact on file, and do not release until an escort arrives or a documented alternative (e.g. supervised transport) is arranged.\n\nWhy: Releasing a still-sedated patient without an escort is the single most common preventable sedation discharge failure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: No verified escort — do not release the patient.",
            "role": "front desk / office manager",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "front-desk",
          "title": "No verified escort — do not release the patient",
          "why": "Releasing a still-sedated patient without an escort is the single most common preventable sedation discharge failure."
        },
        {
          "detail": "Read through the written instructions aloud with both the patient and escort present: activity restrictions, diet, warning signs to call about, and after-hours contact number.\n\nWhy: The patient will not reliably recall verbal-only instructions given while still sedated; the escort needs to hear them directly.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Review written post-op instructions with patient and escort",
          "why": "The patient will not reliably recall verbal-only instructions given while still sedated; the escort needs to hear them directly."
        },
        {
          "detail": "Give the physical or digital instruction sheet to the escort, not only the patient, and confirm they have a way to reach the office after hours.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand the escort the written instruction sheet"
        },
        {
          "detail": "Chart the discharge time, final vitals, escort name and relationship, and confirmation that written instructions were provided.\n\nRecord: Chart note: discharge time, vitals, escort name/relationship, instructions-given confirmation.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Document discharge time, vitals, escort, and instructions given"
        },
        {
          "detail": "Front desk receives the case for a scheduled next-day check-in call per the practice's post-op follow-up protocol.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to front desk for the next-day follow-up call"
        },
        {
          "detail": "Sedation discharge complete",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Sedation discharge complete"
        },
        {
          "detail": "Re-check vitals and status at short intervals until the patient meets discharge criteria.",
          "id": "s11",
          "kind": "timer",
          "role": "assistant",
          "timer_seconds": 600,
          "title": "Continue monitoring until criteria are met"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Sedation discharge criteria, escort verification and written post-op instructions — A sedated procedure is complete and the patient is ready to leave.",
      "title": "Sedation discharge criteria, escort verification and written post-op instructions",
      "trigger": "A sedated procedure is complete and the patient is ready to leave",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3 (anesthesia protocols)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3 (anesthesia protocols)"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "sla-010",
      "kind": "clinical",
      "materials": [
        "cold pack",
        "warm compress (later-phase trismus)",
        "chart",
        "referral list for oral/maxillofacial surgery"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Ask the patient to describe onset, location and severity; distinguish trismus (limited opening), hematoma (visible swelling/bruising), facial droop (possible facial nerve involvement), or numbness persisting beyond expected duration.\n\nWhy: Each complication has a different urgency and management path.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Identify the type of complication reported",
          "why": "Each complication has a different urgency and management path."
        },
        {
          "detail": "Route based on the dominant symptom described.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "route-trismus",
              "label": "Limited mouth opening (trismus)"
            },
            {
              "goto": "s7",
              "id": "route-hematoma",
              "label": "Visible swelling or bruising (hematoma)"
            },
            {
              "goto": "s8",
              "id": "route-palsy",
              "label": "Facial droop or asymmetry (possible facial nerve involvement)"
            },
            {
              "goto": "s10",
              "id": "route-numbness",
              "label": "Numbness persisting well beyond expected duration"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "What is the primary complication?"
        },
        {
          "detail": "Advise soft diet, warm compresses after the first 24 hours, gentle jaw-stretching exercises, and NSAIDs only if the dentist confirms no contraindication against the patient's already-documented medical history (e.g. GI bleed history, renal disease, anticoagulant use); schedule a recheck if not improving within a week.\n\nWhy: Most injection-related trismus from a hematoma or muscle trauma resolves conservatively.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Manage trismus with rest, heat and gentle stretching guidance",
          "why": "Most injection-related trismus from a hematoma or muscle trauma resolves conservatively."
        },
        {
          "detail": "Book a recheck within the appropriate window for the complication type, or schedule a follow-up phone call if in-office recheck is not needed.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Schedule a recheck appointment or follow-up call"
        },
        {
          "detail": "Chart the complication type, onset, exam findings, management given, and follow-up or referral plan.\n\nRecord: Chart note: complication type, onset, findings, management, follow-up/referral plan.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Document the complication, management and follow-up plan"
        },
        {
          "detail": "Post-injection complication triaged",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Post-injection complication triaged"
        },
        {
          "detail": "Apply direct pressure and a cold pack for the first hours, advise the patient to expect bruising over several days, and avoid further injections in that site until resolved.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Manage hematoma with cold pack and pressure"
        },
        {
          "detail": "The dentist must personally assess and document the extent of facial droop before deciding between reassurance (transient, from anesthetic spread) and urgent referral (suspected mechanical nerve injury).\n\nWhy: Facial nerve involvement can be transient anesthetic spread into the parotid or a more serious injury, and only a licensed clinician's direct exam can tell these apart.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist personally evaluates possible facial nerve involvement before reassurance or referral.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist personally evaluates possible facial nerve involvement before reassurance or referral",
          "why": "Facial nerve involvement can be transient anesthetic spread into the parotid or a more serious injury, and only a licensed clinician's direct exam can tell these apart."
        },
        {
          "detail": "Transient facial nerve anesthesia typically resolves within hours as the anesthetic wears off.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "palsy-transient",
              "label": "Consistent with transient spread — reassure and monitor until anesthetic wears off"
            },
            {
              "goto": "s12",
              "id": "palsy-persistent",
              "label": "Not resolving as anesthetic wears off — refer for evaluation"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this consistent with transient anesthetic spread?"
        },
        {
          "detail": "Check what agent and technique were used and how long numbness is expected to last; numbness persisting well past that window is a flag for possible nerve injury (paresthesia).",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Establish the numbness timeline against expected duration for the agent used"
        },
        {
          "detail": "Has numbness persisted beyond the expected window (days, not hours)?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "numbness-resolving",
              "label": "Still within expected window — reassure and schedule a recheck"
            },
            {
              "goto": "s12",
              "id": "numbness-prolonged",
              "label": "Persisted well beyond expected duration — refer for evaluation"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "dentist",
          "title": "Has numbness persisted beyond the expected window (days, not hours)?"
        },
        {
          "detail": "Provide the specialist with the agent, technique, site, onset and timeline documented so far, and schedule the referral promptly.",
          "id": "s12",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Refer to oral and maxillofacial surgery for nerve injury evaluation"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Post-injection complications — trismus, hematoma, facial palsy, prolonged numbness — A patient develops swelling, limited opening or persistent numbness after an injection.",
      "title": "Post-injection complications — trismus, hematoma, facial palsy, prolonged numbness",
      "trigger": "A patient develops swelling, limited opening or persistent numbness after an injection",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "source": "AAPD/AAP monitoring guideline for pediatric sedation (open)",
          "url": "https://pediatrics.aappublications.org/content/143/6/e20191000"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3 (pediatric anesthesia note — weight-based dosing, default agent)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3 (pediatric anesthesia note — weight-based dosing, default agent)"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-patient",
      "id": "sla-011",
      "kind": "clinical",
      "materials": [
        "cotton roll or lip guard (optional)",
        "written warning card for caregiver"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Flag young children and patients with developmental or cognitive differences who are being dismissed while lip, cheek or tongue is still anesthetized.\n\nWhy: These groups are the population most likely to chew on numb tissue without noticing, per the AAPD/AAP guideline's caregiver-education emphasis.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Identify patients at elevated risk of self-biting while numb",
          "why": "These groups are the population most likely to chew on numb tissue without noticing, per the AAPD/AAP guideline's caregiver-education emphasis."
        },
        {
          "detail": "Explain in plain language, at the patient's level where appropriate, that the lip, cheek or tongue is numb and must not be bitten, sucked on, or chewed until feeling returns.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Give a clear verbal warning to the patient and caregiver"
        },
        {
          "detail": "State the approximate time until normal sensation returns for the agent used, so the caregiver knows how long to actively watch the patient.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Explain the expected duration of numbness"
        },
        {
          "detail": "Consider offering a cotton roll or soft guard for very young or high-risk patients during the ride home.",
          "forks": [
            {
              "goto": "s8",
              "id": "guard-offer",
              "label": "High-risk patient — offer a lip/cheek guard for the ride home"
            },
            {
              "advised": true,
              "goto": "s5",
              "id": "guard-not-needed",
              "label": "Verbal warning is sufficient"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "assistant",
          "title": "Is a physical lip/cheek guard appropriate for this patient?"
        },
        {
          "detail": "Give the caregiver a card restating the warning and expected numbness duration in writing, to reinforce the verbal instruction.\n\nWhy: A caregiver distracted on the drive home is more likely to recall a card they can glance at than a verbal instruction alone.",
          "id": "s5",
          "kind": "step",
          "role": "assistant",
          "title": "Hand the caregiver a written warning card",
          "why": "A caregiver distracted on the drive home is more likely to recall a card they can glance at than a verbal instruction alone."
        },
        {
          "detail": "Note in the chart that the biting-risk warning was given verbally and in writing to the caregiver.\n\nRecord: Chart note: biting-risk warning given, caregiver acknowledged.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Document that the warning was given"
        },
        {
          "detail": "Biting-risk warning delivered",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Biting-risk warning delivered"
        },
        {
          "detail": "Show the caregiver how the guard is placed and how long to keep it in place.",
          "id": "s8",
          "kind": "step",
          "role": "assistant",
          "title": "Provide and demonstrate use of the guard"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Lip and cheek biting prevention after anesthesia (children, special needs) — A child or vulnerable patient is dismissed while still numb.",
      "title": "Lip and cheek biting prevention after anesthesia (children, special needs)",
      "trigger": "A child or vulnerable patient is dismissed while still numb",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        },
        {
          "kind": "generic",
          "label": "DOCS/TECHNICAL_PROTOCOLS.md §3 (anesthesia protocols — needle handling)",
          "source": "DOCS/TECHNICAL_PROTOCOLS.md §3 (anesthesia protocols — needle handling)"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "sla-012",
      "kind": "clinical",
      "materials": [
        "hemostat (if visible fragment)",
        "incident report form",
        "imaging referral order"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "The treating dentist stops all further manipulation at the site, keeps the patient still, and personally assesses whether any part of the needle is visible above the tissue surface.\n\nWhy: Attempting removal with the wrong instrument or continuing to probe can push a fragment deeper; this is a licensed clinical decision from the first second.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist stops the procedure and personally assesses the break.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s1",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist stops the procedure and personally assesses the break",
          "why": "Attempting removal with the wrong instrument or continuing to probe can push a fragment deeper; this is a licensed clinical decision from the first second."
        },
        {
          "detail": "Is a portion of the fragment visible and graspable?",
          "forks": [
            {
              "goto": "s8",
              "id": "fragment-visible",
              "label": "Visible and graspable — attempt retrieval with a hemostat"
            },
            {
              "advised": true,
              "goto": "s3",
              "id": "fragment-not-visible",
              "label": "Not visible — do not probe further, proceed to imaging"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is a portion of the fragment visible and graspable?"
        },
        {
          "detail": "Order appropriate imaging (e.g. radiograph or CT as indicated) to localize the fragment before deciding on surgical retrieval.\n\nWhy: A fragment that migrated or is not visible needs imaging localization before any surgical plan.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Order imaging to locate the remaining fragment",
          "why": "A fragment that migrated or is not visible needs imaging localization before any surgical plan."
        },
        {
          "detail": "Provide the referral with the imaging, injection site, needle type and gauge, and timeline; same-day referral for an urgent surgical opinion.",
          "id": "s4",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Refer to oral and maxillofacial surgery for surgical retrieval evaluation"
        },
        {
          "detail": "Explain plainly what happened, what has been done, and the referral plan; answer questions honestly.\n\nWhy: Transparent disclosure of an adverse incident is both an ethical and risk-management obligation.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Explain the incident and next steps to the patient",
          "why": "Transparent disclosure of an adverse incident is both an ethical and risk-management obligation."
        },
        {
          "detail": "Chart the full sequence of events, retrieval attempt(s), imaging ordered, referral made, and patient discussion; file an internal incident report per the practice's risk-management process.\n\nRecord: Chart note + incident report: sequence of events, retrieval attempts, imaging, referral, patient discussion.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document the incident and file an internal incident report"
        },
        {
          "detail": "Needle breakage incident handled",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Needle breakage incident handled"
        },
        {
          "detail": "If a portion is clearly visible above the tissue, grasp and remove it with a hemostat in a single controlled motion; do not attempt more than one careful attempt.\n\nWhy: One controlled attempt on a visibly graspable fragment is reasonable; repeated attempts risk pushing it deeper.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Attempt retrieval with a hemostat",
          "why": "One controlled attempt on a visibly graspable fragment is reasonable; repeated attempts risk pushing it deeper."
        },
        {
          "detail": "Was the fragment fully retrieved?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "retrieval-success",
              "label": "Fully retrieved and accounted for"
            },
            {
              "goto": "s3",
              "id": "retrieval-failed",
              "label": "Not fully retrieved or uncertain"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "dentist",
          "title": "Was the fragment fully retrieved?"
        },
        {
          "detail": "Compare the retrieved piece against the remaining attached portion to confirm the full needle length is accounted for.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the retrieved fragment plus the remaining needle equal a complete needle"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Needle breakage during injection — retrieval decision and referral — A needle fractures in tissue.",
      "title": "Needle breakage during injection — retrieval decision and referral",
      "trigger": "A needle fractures in tissue",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Dental Board of California sedation permits (B&P §1646–1647)",
          "source": "Dental Board of California sedation permits (B&P §1646–1647)",
          "url": "https://www.dbc.ca.gov/"
        },
        {
          "kind": "regulation",
          "label": "No Cal/OSHA or federal regulation specifically mandates dental nitrous-oxide scavenging equipment, fail-safe valve testing, or titration/recovery procedure; Title 8 CCR §5155 (Airborne Contaminants) sets a general permissible exposure limit for nitrous oxide (50 ppm 8-hr TWA) that bears only on the staff-exposure-monitoring slice of sla-006/sla-013, not on scavenging equipment, fail-safe testing, or titration/recovery — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "No Cal/OSHA or federal regulation specifically mandates dental nitrous-oxide scavenging equipment, fail-safe valve testing, or titration/recovery procedure; Title 8 CCR §5155 (Airborne Contaminants) sets a general permissible exposure limit for nitrous oxide (50 ppm 8-hr TWA) that bears only on the staff-exposure-monitoring slice of sla-006/sla-013, not on scavenging equipment, fail-safe testing, or titration/recovery — generic functional equivalent"
          },
          "repaired": {
            "action": "generic",
            "evidence": "Independently searched for a CA-specific nitrous-oxide scavenging/dental-operatory regulation and found none; Cal/OSHA has no dedicated standard for N2O scavenging equipment. The closest real, verifiable authority is Title 8 CCR §5155 (dir.ca.gov/title8/5155.html), which sets the airborne-contaminant PEL (50 ppm TWA) — a general workplace-exposure ceiling, not an equipment, fail-safe-test, or titration/recovery requirement. §5142 (the round-one source, confirmed again by direct read) is HVAC minimum outdoor-air ventilation and never mentions nitrous oxide.",
            "ticket": "PROT-017",
            "was": {
              "source": "Cal/OSHA (DOSH) Title 8 CCR §5142 — Mechanically Driven Heating, Ventilating and Air Conditioning (HVAC) Systems to Provide Minimum Building Ventilation",
              "url": "https://www.dir.ca.gov/title8/5142.html"
            }
          },
          "source": "No Cal/OSHA or federal regulation specifically mandates dental nitrous-oxide scavenging equipment, fail-safe valve testing, or titration/recovery procedure; Title 8 CCR §5155 (Airborne Contaminants) sets a general permissible exposure limit for nitrous oxide (50 ppm 8-hr TWA) that bears only on the staff-exposure-monitoring slice of sla-006/sla-013, not on scavenging equipment, fail-safe testing, or titration/recovery — Practice policy — no published authority governs this step."
        },
        {
          "kind": "public_domain",
          "label": "NIOSH nitrous oxide exposure control guidance",
          "source": "NIOSH nitrous oxide exposure control guidance",
          "url": "https://www.cdc.gov/niosh/docs/94-129/default.html"
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "daily",
      "id": "sla-013",
      "kind": "clinical",
      "materials": [
        "nitrous oxide delivery unit",
        "scavenging mask and hoses",
        "fail-safe test checklist",
        "exposure monitoring badge or log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "dentist",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm: gas cylinders are secured and adequately filled, hoses show no visible damage, the fail-safe (oxygen fail-safe shutoff) engages when oxygen supply is interrupted, and the minimum oxygen flow default is functioning.\n\nWhy: Per Cal/OSHA nitrous scavenging requirements, a fail-safe check before first daily use catches an equipment fault before a patient is exposed.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Perform the daily nitrous unit startup and fail-safe check before first patient use",
          "why": "Per Cal/OSHA nitrous scavenging requirements, a fail-safe check before first daily use catches an equipment fault before a patient is exposed."
        },
        {
          "detail": "Did the equipment pass the fail-safe and scavenging check?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "equipment-pass",
              "label": "Passed — clear the unit for use today"
            },
            {
              "goto": "s9",
              "id": "equipment-fail",
              "label": "Failed any item — take the unit out of service"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "assistant",
          "title": "Did the equipment pass the fail-safe and scavenging check?"
        },
        {
          "detail": "Record the date, time, and initials of who performed the daily fail-safe and scavenging check.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Log the passing daily check"
        },
        {
          "detail": "Is the periodic staff exposure survey or scavenging leak test due, or has a staff pregnancy been disclosed?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "survey-due",
              "label": "Due, or a pregnancy was disclosed — run the exposure survey now"
            },
            {
              "goto": "s8",
              "id": "survey-not-due",
              "label": "Not due — daily check is sufficient today"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is the periodic staff exposure survey or scavenging leak test due, or has a staff pregnancy been disclosed?"
        },
        {
          "detail": "Measure ambient nitrous levels in the operatory during a representative case and compare to the NIOSH recommended exposure limit; inspect scavenging connections for leaks.\n\nWhy: Per NIOSH nitrous oxide exposure control guidance, periodic ambient monitoring (not just equipment inspection) is what actually confirms staff exposure is controlled.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Run the staff exposure survey and scavenging leak test",
          "why": "Per NIOSH nitrous oxide exposure control guidance, periodic ambient monitoring (not just equipment inspection) is what actually confirms staff exposure is controlled."
        },
        {
          "detail": "Is ambient exposure within the recommended limit?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "exposure-ok",
              "label": "Within limit — document and continue routine use"
            },
            {
              "goto": "s11",
              "id": "exposure-exceeded",
              "label": "Exceeded limit — restrict use and remediate scavenging or ventilation"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "compliance-officer",
          "title": "Is ambient exposure within the recommended limit?"
        },
        {
          "detail": "Record the survey date, measured levels, comparison to the recommended limit, and any remediation taken.\n\nRecord: Exposure survey log: date, measured levels, limit comparison, remediation.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the survey result and any remediation"
        },
        {
          "detail": "Nitrous equipment and exposure check complete",
          "id": "s8",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Nitrous equipment and exposure check complete"
        },
        {
          "detail": "Tag the unit out of service, do not use it for any patient, and notify the compliance officer to arrange service before it is used again.\n\nWhy: A failed fail-safe or scavenging check means a patient or staff exposure risk that cannot be worked around informally.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Take the unit out of service and notify the compliance officer.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s9",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Take the unit out of service and notify the compliance officer",
          "why": "A failed fail-safe or scavenging check means a patient or staff exposure risk that cannot be worked around informally."
        },
        {
          "detail": "Record what failed, the date, and the service request made.\n\nRecord: Equipment log: failure description, date, service request status.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the equipment issue and service request"
        },
        {
          "detail": "Restrict nitrous use in the operatory, reassign any pregnant or otherwise flagged staff away from the space, and arrange scavenging or ventilation remediation before resuming routine use.\n\nWhy: Exceeding a recognized occupational exposure limit is a staff safety issue that outranks scheduling convenience.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Restrict nitrous use in the affected operatory until remediated.",
            "role": "compliance officer",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Restrict nitrous use in the affected operatory until remediated",
          "why": "Exceeding a recognized occupational exposure limit is a staff safety issue that outranks scheduling convenience."
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Nitrous oxide equipment check, fail-safe test, scavenging and staff exposure monitoring — Daily equipment start, the periodic exposure survey, equipment service, or a staff pregnancy is disclosed.",
      "title": "Nitrous oxide equipment check, fail-safe test, scavenging and staff exposure monitoring",
      "trigger": "Daily equipment start, the periodic exposure survey, equipment service, or a staff pregnancy is disclosed",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "repaired": {
            "action": "reduce",
            "evidence": "Per the audit's own file-verified read of the source (`file` confirmed the stored PDF is the actual ADA guideline document): the ADA 'Guidelines for the Use of Sedation and General Anesthesia by Dentists' (2016) governs moderate/deep sedation and general anesthesia — pre-op assessment, continuous pulse-oximetry/capnography/ECG monitoring, and recovery/discharge criteria — matching sla-001 (pre-anesthetic assessment) and sla-007/008/009 (sedation permit/monitoring/discharge) directly.",
            "ticket": "PROT-017",
            "was": {
              "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (open)",
              "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
            }
          },
          "source": "ADA Guidelines for the Use of Sedation and General Anesthesia by Dentists (2016) — pre-anesthetic assessment, sedation permit levels, continuous monitoring, and discharge criteria for moderate/deep sedation and general anesthesia (does not address local-anesthesia injection technique or injection complications)",
          "url": "https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/library/oral-health-topics/ada_sedation_use_guidelines.pdf"
        },
        {
          "kind": "generic",
          "label": "For facility case-coordination workflow — no institute or facility-vendor process reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for facility case-coordination workflow — no institute or facility-vendor process reproduced"
          },
          "source": "For facility case-coordination workflow — no institute or facility-vendor process reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "sedation-local-anesthesia",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "sla-014",
      "kind": "clinical",
      "materials": [
        "hospital privileges file",
        "history and physical (H&P) form",
        "facility scheduling system",
        "insurance prior-authorization request"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "scheduler",
        "insurance-coordinator",
        "specialist-referral"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check that the treating dentist's privileges at the hospital or surgery center are current and cover the planned procedure.\n\nWhy: A case cannot be scheduled at a facility where privileges have lapsed or do not cover the procedure type.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm the dentist holds current privileges at the target facility",
          "why": "A case cannot be scheduled at a facility where privileges have lapsed or do not cover the procedure type."
        },
        {
          "detail": "Are privileges current and sufficient for this case?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "privileges-ok",
              "label": "Current and sufficient — proceed to scheduling"
            },
            {
              "goto": "s11",
              "id": "privileges-lapsed",
              "label": "Lapsed or insufficient — resolve with the facility credentialing office first"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Are privileges current and sufficient for this case?"
        },
        {
          "detail": "Contact the facility scheduling office to request an available OR or procedure-room date that also works for the patient and any needed support staff.",
          "id": "s3",
          "kind": "step",
          "role": "scheduler",
          "title": "Request an available facility date"
        },
        {
          "detail": "Confirm whether the facility requires the H&P from the patient's physician or an anesthesiologist pre-op clinic, and schedule it to complete within the facility's required window before the case date.\n\nWhy: Most facilities will cancel a case same-day if the H&P is missing or outside the required validity window.",
          "id": "s4",
          "kind": "step",
          "role": "scheduler",
          "title": "Arrange the required history and physical (H&P)",
          "why": "Most facilities will cancel a case same-day if the H&P is missing or outside the required validity window."
        },
        {
          "detail": "Submit the prior-authorization request for the facility fee, anesthesia, and procedure, including supporting clinical documentation.",
          "id": "s5",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Submit the insurance prior-authorization request"
        },
        {
          "detail": "Was prior authorization approved before the case date?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "auth-approved",
              "label": "Approved — proceed to case confirmation"
            },
            {
              "goto": "s12",
              "id": "auth-pending-or-denied",
              "label": "Still pending or denied close to the case date"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Was prior authorization approved before the case date?"
        },
        {
          "detail": "The treating dentist confirms privileges, H&P, and authorization are all in place and the case plan is still clinically appropriate before final confirmation to the facility.\n\nWhy: Final go/no-go on a general-anesthesia case is a licensed clinical decision, not an administrative checkbox.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treating dentist confirms the case is ready to proceed.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Treating dentist confirms the case is ready to proceed",
          "why": "Final go/no-go on a general-anesthesia case is a licensed clinical decision, not an administrative checkbox."
        },
        {
          "detail": "Send final case confirmation to the facility scheduling office and to any specialist co-treating the case, with all required documentation attached.",
          "id": "s8",
          "kind": "step",
          "role": "specialist-referral",
          "title": "Confirm the case with the facility and any co-treating specialist"
        },
        {
          "detail": "Record privileging status, H&P completion date, authorization status, and facility confirmation date in the case file.\n\nRecord: Case coordination log: privileging, H&P date, authorization status, facility confirmation.",
          "id": "s9",
          "kind": "step",
          "role": "scheduler",
          "title": "Document the coordination timeline and confirmations"
        },
        {
          "detail": "Facility case coordination complete",
          "id": "s10",
          "kind": "step",
          "role": "scheduler",
          "title": "Facility case coordination complete"
        },
        {
          "detail": "Contact the facility's credentialing office to renew or expand privileges; do not proceed to scheduling until resolved.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Resolve privileging with the facility before scheduling"
        },
        {
          "detail": "Contact the payer directly, submit any requested peer-to-peer review, and inform the patient of the status; do not proceed to the facility with an unresolved authorization.",
          "id": "s12",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Escalate the pending or denied authorization"
        }
      ],
      "subclass": "local-anesthesia-nitrous-and-sedation",
      "summary": "Hospital or ambulatory-surgery-center case coordination (privileges, H&P, scheduling, billing) — A patient needs treatment under general anesthesia in a hospital or surgery center.",
      "title": "Hospital or ambulatory-surgery-center case coordination (privileges, H&P, scheduling, billing)",
      "trigger": "A patient needs treatment under general anesthesia in a hospital or surgery center",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard — contaminated sharps containment and transport",
          "source": "OSHA Bloodborne Pathogens Standard — contaminated sharps containment and transport",
          "url": "https://www.osha.gov/bloodborne-pathogens"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "srm-001",
      "kind": "clinical",
      "materials": [
        "puncture-resistant, leak-proof transport container with lid",
        "biohazard label",
        "utility gloves",
        "cart or tray for transport"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Put on utility gloves and, if splash risk is present, mask and eye protection before touching any used instrument.\n\nWhy: Bloodborne pathogen exposure control applies to every contact with contaminated instruments (OSHA Bloodborne Pathogens Standard).",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Don PPE before handling contaminated instruments",
          "why": "Bloodborne pathogen exposure control applies to every contact with contaminated instruments (OSHA Bloodborne Pathogens Standard)."
        },
        {
          "detail": "Immediately after the procedure, place all used instruments — sharps and non-sharps — into a closed, puncture-resistant, leak-proof, biohazard-labeled container. Never hand-carry loose instruments or recap needles.\n\nWhy: Open or loose transport is the leading cause of sharps injuries between operatory and sterilization.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Sort and contain instruments at chairside",
          "why": "Open or loose transport is the leading cause of sharps injuries between operatory and sterilization."
        },
        {
          "detail": "Confirm the container is closed and latched, carries a visible biohazard label, is not overfilled above its fill line, and shows no visible leakage.",
          "id": "s3",
          "kind": "step",
          "role": "assistant",
          "title": "Verify the container before it leaves the room"
        },
        {
          "detail": "Carry the closed container directly to the dirty side of the sterilization area using the practice's designated route — never through patient-facing areas.\n\nWhy: Avoids cross-contaminating clean, patient-facing, or reception spaces.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Transport to the dirty side",
          "why": "Avoids cross-contaminating clean, patient-facing, or reception spaces."
        },
        {
          "detail": "Is the sterilization area staffed and ready to receive the container?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "ready",
              "label": "Sterilization tech is present and ready"
            },
            {
              "goto": "s9",
              "id": "not-ready",
              "label": "No one is available yet"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Is the sterilization area staffed and ready to receive the container?"
        },
        {
          "detail": "The sterilization tech receives the sealed container, confirms the label and seal are intact, and takes custody of it.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off to the sterilization tech"
        },
        {
          "detail": "Record the transport time, originating operatory, and receiving tech's initials in the daily sterilization log.\n\nRecord: Daily sterilization intake log",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log receipt"
        },
        {
          "detail": "Instruments received at dirty side",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Instruments received at dirty side"
        },
        {
          "detail": "Place the closed, sealed container on the designated dirty-side holding shelf. Do not open it or begin sorting contents until a sterilization tech is present.\n\nWhy: Staging keeps the container contained rather than left open or unattended in a work area.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Stage the container",
          "why": "Staging keeps the container contained rather than left open or unattended in a work area."
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Contaminated instrument transport in closed, puncture-resistant, labeled containers — Instruments leave the operatory after a procedure — no hand-carrying loose sharps.",
      "title": "Contaminated instrument transport in closed, puncture-resistant, labeled containers",
      "trigger": "Instruments leave the operatory after a procedure — no hand-carrying loose sharps",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "srm-002",
      "kind": "clinical",
      "materials": [
        "heavy-duty utility gloves, mask, eye or face protection, fluid-resistant gown",
        "enzymatic pre-soak solution",
        "instrument cassette or tray",
        "dirty-side sink or soak basin"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Put on heavy-duty utility gloves, mask, eye or face protection, and a fluid-resistant gown before opening any transport container.\n\nWhy: Receiving and sorting contaminated instruments is the highest-splash-risk task in reprocessing.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Don full dirty-side PPE",
          "why": "Receiving and sorting contaminated instruments is the highest-splash-risk task in reprocessing."
        },
        {
          "detail": "Open the transport container on the dirty-side counter and visually confirm the contents match what was sent — no missing sharps or instruments.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Open and confirm contents"
        },
        {
          "detail": "Sort by type and material: open hinged instruments fully, separate delicate or sharp items, and disassemble multi-part instruments per manufacturer instructions.\n\nWhy: Prevents instrument damage and ensures cleaning solution reaches every surface in the next step.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Sort instruments",
          "why": "Prevents instrument damage and ensures cleaning solution reaches every surface in the next step."
        },
        {
          "detail": "Will cleaning begin within the manufacturer's hold-time window?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "prompt",
              "label": "Cleaning starts promptly, within hold time"
            },
            {
              "goto": "s10",
              "id": "delayed",
              "label": "Cleaning will be delayed"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Will cleaning begin within the manufacturer's hold-time window?"
        },
        {
          "detail": "Move sorted (and, if applicable, pre-soaked) instruments onto the cleaning station tray in preparation for the cleaning step.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Transfer to cleaning station"
        },
        {
          "detail": "Confirm the sharps container has capacity, and disinfect and return the empty transport container for reuse before leaving the area.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Reset the receiving station"
        },
        {
          "detail": "Record receipt time, item count and type, and whether pre-soak was used in the sterilization log.\n\nRecord: Daily sterilization intake log",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the batch"
        },
        {
          "detail": "Hand the sorted, labeled tray to the cleaning step (self or next-shift tech).",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off to cleaning"
        },
        {
          "detail": "Batch ready for cleaning",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Batch ready for cleaning"
        },
        {
          "detail": "Submerge sorted instruments in enzymatic pre-soak solution at the labeled concentration and contact time to prevent bioburden from drying onto the surface.\n\nWhy: Dried bioburden is harder to remove mechanically and can shield microorganisms from the sterilant.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Pre-soak",
          "why": "Dried bioburden is harder to remove mechanically and can shield microorganisms from the sterilant."
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Receiving, sorting and pre-soaking contaminated instruments on the dirty side — A transport container arrives at the dirty side of the sterilization area.",
      "title": "Receiving, sorting and pre-soaking contaminated instruments on the dirty side",
      "trigger": "A transport container arrives at the dirty side of the sterilization area",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "srm-003",
      "kind": "clinical",
      "materials": [
        "ultrasonic cleaner or washer-disinfector",
        "enzymatic detergent",
        "rinse water station",
        "lint-free towel",
        "magnifying loupe or lighted magnifier"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Don PPE and load the ultrasonic cleaner or washer-disinfector per manufacturer instructions, avoiding overlap or overloading of instruments.\n\nWhy: Overloading blocks solution contact and leaves bioburden on shielded surfaces.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Load the cleaning equipment",
          "why": "Overloading blocks solution contact and leaves bioburden on shielded surfaces."
        },
        {
          "detail": "Ultrasonic bath or washer-disinfector cycle?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "washer",
              "label": "Washer-disinfector cycle"
            },
            {
              "goto": "s10",
              "id": "ultrasonic",
              "label": "Ultrasonic bath cycle"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Ultrasonic bath or washer-disinfector cycle?"
        },
        {
          "detail": "Rinse instruments thoroughly under running water to remove detergent residue.\n\nWhy: Residual cleaning chemical can interfere with sterilant contact and with chemical indicator readings.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Rinse",
          "why": "Residual cleaning chemical can interfere with sterilant contact and with chemical indicator readings."
        },
        {
          "detail": "Dry instruments with a lint-free towel or the equipment's drying cycle before inspection.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Dry"
        },
        {
          "detail": "Visually inspect each instrument under magnification for residual debris, corrosion, pitting, and damage to hinges, tips, and cutting edges.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Inspect under magnification"
        },
        {
          "detail": "Does the instrument pass inspection?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pass",
              "label": "Clean, intact, no damage"
            },
            {
              "goto": "s11",
              "id": "fail",
              "label": "Debris, corrosion, or damage found"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Does the instrument pass inspection?"
        },
        {
          "detail": "Record cleaning method used, cycle time, and inspection outcome (pass/fail count) in the sterilization log.\n\nRecord: Instrument cleaning and inspection log",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the cleaning batch"
        },
        {
          "detail": "Hand off inspected, dried, passing instruments to the packaging station.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off to packaging"
        },
        {
          "detail": "Instruments cleaned and inspected",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Instruments cleaned and inspected"
        },
        {
          "detail": "Run the ultrasonic cycle with fresh enzymatic solution for the manufacturer-specified time, lid closed throughout.\n\nWhy: An open ultrasonic bath aerosolizes bioburden into the room air.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Run the ultrasonic cycle",
          "why": "An open ultrasonic bath aerosolizes bioburden into the room air."
        },
        {
          "detail": "Set aside failed or damaged instruments for re-cleaning, repair, or removal from service. Do not package them for sterilization.\n\nWhy: Sterilization cannot compensate for a soiled or physically damaged instrument.",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Set aside failed instruments",
          "why": "Sterilization cannot compensate for a soiled or physically damaged instrument."
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Instrument cleaning — ultrasonic or washer-disinfector, rinse, visual inspection — A batch is ready to clean.",
      "title": "Instrument cleaning — ultrasonic or washer-disinfector, rinse, visual inspection",
      "trigger": "A batch is ready to clean",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "FDA device classification — Sterilization wrap (21 CFR 880.6850)",
          "source": "FDA device classification — Sterilization wrap (21 CFR 880.6850)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-880/subpart-G/section-880.6850"
        },
        {
          "kind": "regulation",
          "label": "FDA device classification — Sterilization process indicator (21 CFR 880.2800)",
          "source": "FDA device classification — Sterilization process indicator (21 CFR 880.2800)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-880/subpart-C/section-880.2800"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 12,
      "frequency": "per-use",
      "id": "srm-004",
      "kind": "clinical",
      "materials": [
        "sterilization pouches or wrap",
        "internal chemical indicator strips",
        "external process indicator tape or pouch printing",
        "load/lot label",
        "permanent marker or label printer"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm instruments are clean, dry, and passed inspection before packaging. Wet or debris-laden instruments are not packaged.\n\nWhy: Residual moisture prevents sterilant penetration and causes wet-pack contamination after the cycle.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Confirm instruments are ready to package",
          "why": "Residual moisture prevents sterilant penetration and causes wet-pack contamination after the cycle."
        },
        {
          "detail": "Select an appropriately sized pouch or wrap for the instrument or set — avoid overstuffing or tenting that blocks sterilant contact.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Select packaging"
        },
        {
          "detail": "Place an internal chemical indicator inside each package, positioned at the point hardest for sterilant to reach (typically the center of a set).\n\nWhy: The internal indicator verifies the sterilant actually reached the instrument, not just the outside of the package.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Place the internal chemical indicator",
          "why": "The internal indicator verifies the sterilant actually reached the instrument, not just the outside of the package."
        },
        {
          "detail": "Seal the package and verify the external process indicator (heat-sensitive tape or printed pouch marker) is visible and unused on the outside.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Seal and apply the external indicator"
        },
        {
          "detail": "Label each package with contents, packaging date, and the sterilizer/cycle/load identifier and technician initials it will be assigned to, for lot control and recall traceability.\n\nWhy: Enables tracing every package back to its exact cycle if a load later fails a monitoring check.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Label for traceability",
          "why": "Enables tracing every package back to its exact cycle if a load later fails a monitoring check."
        },
        {
          "detail": "Verify no package exceeds the sterilizer manufacturer's maximum load density before staging packages for loading.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Check load density before staging"
        },
        {
          "detail": "Record package count, lot numbers, and contents by set type.\n\nRecord: Packaging and indicator log",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the packaged batch"
        },
        {
          "detail": "Hand off packaged, labeled packages to the sterilizer loading and cycle step.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off to sterilizer loading"
        },
        {
          "detail": "Instruments packaged and ready to load",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Instruments packaged and ready to load"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Inspection, packaging, internal and external indicator placement and labeling — Instruments are clean, inspected and dry.",
      "title": "Inspection, packaging, internal and external indicator placement and labeling",
      "trigger": "Instruments are clean, inspected and dry",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California 16 CCR §1005 (sterilization monitoring and logs)",
          "source": "Dental Board of California 16 CCR §1005 (sterilization monitoring and logs)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1005"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "per-use",
      "id": "srm-005",
      "kind": "clinical",
      "materials": [
        "autoclave or other sterilizer",
        "cycle log sheet or digital log",
        "packaged loads with internal/external indicators already placed",
        "load rack or cart"
      ],
      "needs_ack_review": true,
      "record": {
        "fields": [
          "operator_role",
          "operator_ref",
          "sterilizer_id",
          "cycle_number",
          "cycle_type",
          "load_id",
          "mechanical_indicator",
          "chemical_indicator",
          "corroboration",
          "attested_by_role",
          "attested_at",
          "retention"
        ],
        "kind": "sterilization"
      },
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Load packaged items into the sterilizer per the manufacturer's loading pattern — indicators facing correctly, packages not touching the chamber walls, adequate spacing for sterilant circulation.\n\nWhy: Poor loading blocks sterilant contact with package surfaces and is a leading cause of load failures.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Load the sterilizer",
          "why": "Poor loading blocks sterilant contact with package surfaces and is a leading cause of load failures."
        },
        {
          "detail": "Select the cycle and parameters matched to the load type (wrapped or unwrapped, instrument material) per the manufacturer's instructions.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Select cycle and parameters"
        },
        {
          "detail": "Start the cycle and record start time, cycle number, and load contents on the cycle log.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Start the cycle and log the start"
        },
        {
          "detail": "Wait for the complete sterilization and dry-time cycle to finish; do not open the door early.\n\nWhy: Interrupting a cycle voids sterilization and the entire load must be reprocessed from packaging.",
          "id": "s4",
          "kind": "timer",
          "role": "sterilization-tech",
          "timer_seconds": 2700,
          "title": "Run the full cycle",
          "why": "Interrupting a cycle voids sterilization and the entire load must be reprocessed from packaging."
        },
        {
          "detail": "After the cycle ends, review the sterilizer's mechanical printout or display (temperature, pressure, time achieved) and confirm the external and internal chemical indicators changed to the correct pass state before removing the load.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Read cycle results"
        },
        {
          "detail": "Did all mechanical and chemical parameters pass?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "pass",
              "label": "All parameters and indicators passed"
            },
            {
              "goto": "s11",
              "id": "fail",
              "label": "Any parameter or indicator failed"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Did all mechanical and chemical parameters pass?"
        },
        {
          "detail": "Allow packages to cool undisturbed on the rack per manufacturer guidance before handling.\n\nWhy: Handling a hot, damp load causes wet-pack contamination.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Cool the load",
          "why": "Handling a hot, damp load causes wet-pack contamination."
        },
        {
          "detail": "Record final cycle parameters, indicator results, and the release decision (released or quarantined) on the cycle log, initialed by the releasing tech.\n\nWhy: This protocol's hitl model relies on the releasing tech's own indicator-reading self-attestation on a passing load — the gate at n7 is reserved for failures, so the initialed log entry is the accountability record for a routine release.\n\nRecord: Sterilizer cycle log",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the final result and decision",
          "why": "This protocol's hitl model relies on the releasing tech's own indicator-reading self-attestation on a passing load — the gate at n7 is reserved for failures, so the initialed log entry is the accountability record for a routine release."
        },
        {
          "detail": "Released packages are handed to sterile storage; quarantined loads are handed to the office manager and compliance officer for follow-up.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off the load"
        },
        {
          "detail": "Load released or quarantined",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Load released or quarantined"
        },
        {
          "detail": "Do not release any package from this load for patient use. Quarantine all packages, notify the office manager, and open the positive/failed-load response and recall protocol before any instrument from this load is used.\n\nWhy: Releasing a load with an unverified sterilization outcome risks a non-sterile instrument reaching a patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Quarantine the load before any release decision.",
            "role": "office manager or sterilization-tech lead",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "sterilization-tech",
          "title": "Quarantine the load before any release decision",
          "why": "Releasing a load with an unverified sterilization outcome risks a non-sterile instrument reaching a patient."
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Sterilizer loading, cycle selection, parameter verification and load release — A packaged load is ready — cycle parameters and indicators are confirmed before release.",
      "title": "Sterilizer loading, cycle selection, parameter verification and load release",
      "trigger": "A packaged load is ready — cycle parameters and indicators are confirmed before release",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — all handpieces sterilized between patients",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — all handpieces sterilized between patients",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "OSHA Bloodborne Pathogens Standard",
          "source": "OSHA Bloodborne Pathogens Standard",
          "url": "https://www.osha.gov/bloodborne-pathogens"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "srm-006",
      "kind": "clinical",
      "materials": [
        "handpiece flushing/purge attachment per manufacturer",
        "manufacturer-approved handpiece exterior cleaning wipe or solution",
        "manufacturer-approved handpiece lubricant",
        "sterilization pouch sized for handpieces",
        "heat sterilizer (autoclave)"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Wipe visible bioburden from the handpiece exterior and run the flush/purge cycle per manufacturer instructions before removing it from the operatory.\n\nWhy: Bioburden left to dry is harder to remove and can be drawn into internal components during the next use.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Purge immediately after use",
          "why": "Bioburden left to dry is harder to remove and can be drawn into internal components during the next use."
        },
        {
          "detail": "Transport the handpiece to sterilization in a closed container along with other contaminated instruments — never hand-carried loose.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Transport with other contaminated instruments"
        },
        {
          "detail": "Clean the exterior and, where the manufacturer specifies, internal components using the manufacturer-approved cleaning method. Never immerse in liquid or an ultrasonic bath unless the manufacturer explicitly allows it.\n\nWhy: Handpieces contain internal mechanisms that liquid immersion can damage.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Clean the handpiece",
          "why": "Handpieces contain internal mechanisms that liquid immersion can damage."
        },
        {
          "detail": "Lubricate per the manufacturer's instructions and cycle sequence before bagging — many handpieces require lubrication before, not after, sterilization.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Lubricate"
        },
        {
          "detail": "Bag the handpiece individually in a sterilization pouch sized to avoid crushing, with internal and external indicators placed as in standard packaging.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Bag individually"
        },
        {
          "detail": "Heat-sterilize using the manufacturer-validated cycle. Never cold-sterilize, wipe only, or skip a cycle between patients.\n\nWhy: Cold sterilization and surface wiping do not reach the internal bore of a handpiece; CDC and OSHA guidance requires heat sterilization of all handpieces between patients.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Heat-sterilize between every patient",
          "why": "Cold sterilization and surface wiping do not reach the internal bore of a handpiece; CDC and OSHA guidance requires heat sterilization of all handpieces between patients."
        },
        {
          "detail": "Verify cycle indicators and mechanical parameters passed before releasing the handpiece for use, the same as any other sterilizer load.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Verify cycle results"
        },
        {
          "detail": "Record the handpiece serial or asset ID, cycle number, and lubrication date for maintenance tracking.\n\nRecord: Handpiece maintenance and sterilization log",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log for maintenance tracking"
        },
        {
          "detail": "Return the sterilized, bagged handpiece to sterile storage or directly to the next operatory setup.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Return to service"
        },
        {
          "detail": "Handpiece reprocessed and ready for reuse",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Handpiece reprocessed and ready for reuse"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Handpiece cleaning, lubrication, bagging and heat sterilization after each use — A handpiece was used on a patient.",
      "title": "Handpiece cleaning, lubrication, bagging and heat sterilization after each use",
      "trigger": "A handpiece was used on a patient",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "source": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1005"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "srm-007",
      "kind": "clinical",
      "materials": [
        "sterilizer printout or digital display",
        "external process indicator on each package",
        "internal chemical indicator inside representative packages",
        "cycle log sheet"
      ],
      "needs_ack_review": true,
      "record": {
        "fields": [
          "operator_role",
          "operator_ref",
          "sterilizer_id",
          "cycle_number",
          "cycle_type",
          "load_id",
          "mechanical_indicator",
          "chemical_indicator",
          "corroboration",
          "attested_by_role",
          "attested_at",
          "retention"
        ],
        "kind": "sterilization"
      },
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "At the end of every cycle, review the sterilizer's mechanical readout (temperature, pressure and time achieved) before opening the door.\n\nWhy: Mechanical monitoring is the first-line, real-time check that the cycle ran within its validated parameters.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Review the mechanical readout",
          "why": "Mechanical monitoring is the first-line, real-time check that the cycle ran within its validated parameters."
        },
        {
          "detail": "Confirm every package's external process indicator changed to the pass state.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Check external indicators on every package"
        },
        {
          "detail": "Open at least one representative package per load type and confirm its internal chemical indicator also passed.\n\nWhy: An external indicator only confirms exposure to the sterilizing agent, not that penetration reached the instrument — the internal indicator is the closer proxy for actual sterility.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Check the internal indicator",
          "why": "An external indicator only confirms exposure to the sterilizing agent, not that penetration reached the instrument — the internal indicator is the closer proxy for actual sterility."
        },
        {
          "detail": "Did mechanical, external, and internal indicators all pass?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "pass",
              "label": "All three checks passed"
            },
            {
              "goto": "s8",
              "id": "fail",
              "label": "Any check failed"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Did mechanical, external, and internal indicators all pass?"
        },
        {
          "detail": "Mark the load released and move it to sterile storage.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Release the load"
        },
        {
          "detail": "Record mechanical readout values, indicator results (pass/fail per check), and the release/quarantine decision on the cycle log, initialed by the tech.\n\nWhy: This protocol's hitl model relies on the tech's own indicator-reading self-attestation on a passing load — the gate at n5 is reserved for failures, so the initialed log entry is the accountability record for a routine release.\n\nRecord: Sterilizer cycle log",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the monitoring result",
          "why": "This protocol's hitl model relies on the tech's own indicator-reading self-attestation on a passing load — the gate at n5 is reserved for failures, so the initialed log entry is the accountability record for a routine release."
        },
        {
          "detail": "Load monitoring complete",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Load monitoring complete"
        },
        {
          "detail": "Do not release the load. Quarantine all packages from this cycle and route to the failed-load response and recall protocol.\n\nWhy: Any single indicator failure means the load's sterility cannot be confirmed, regardless of what the other two checks showed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Quarantine the load.",
            "role": "sterilization-tech lead or office manager",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "sterilization-tech",
          "title": "Quarantine the load",
          "why": "Any single indicator failure means the load's sterility cannot be confirmed, regardless of what the other two checks showed."
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Mechanical and chemical indicator check and cycle log for every load — A sterilizer cycle completes.",
      "title": "Mechanical and chemical indicator check and cycle log for every load",
      "trigger": "A sterilizer cycle completes",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "source": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1005"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 20,
      "frequency": "weekly",
      "id": "srm-008",
      "kind": "clinical",
      "materials": [
        "biological indicator (spore) test vial or strip, one per sterilizer",
        "matched control vial from the same lot, not run through the cycle",
        "incubator or mail-in lab service",
        "spore test log"
      ],
      "needs_ack_review": true,
      "record": {
        "fields": [
          "operator_role",
          "operator_ref",
          "sterilizer_id",
          "cycle_number",
          "cycle_type",
          "load_id",
          "mechanical_indicator",
          "chemical_indicator",
          "biological_indicator",
          "control_indicator",
          "corroboration",
          "attested_by_role",
          "attested_at",
          "retention"
        ],
        "kind": "sterilization"
      },
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "office-manager",
        "compliance-officer",
        "dentist",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Place a biological indicator inside a representative load, or a dedicated test pack, at the least-accessible point in the sterilizer, then run the normal cycle.\n\nWhy: Testing inside a real load reflects actual sterilizing conditions rather than an empty-chamber best case.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Run the test cycle",
          "why": "Testing inside a real load reflects actual sterilizing conditions rather than an empty-chamber best case."
        },
        {
          "detail": "Set aside a matched, unprocessed control indicator from the same lot for comparison.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Set aside a matched control"
        },
        {
          "detail": "Incubate the processed and control indicators per the test system's instructions — in-office incubator or mail-in lab service — and note the incubation start time.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Incubate"
        },
        {
          "detail": "Wait the manufacturer-specified incubation period for a readable result.",
          "id": "s4",
          "kind": "timer",
          "role": "sterilization-tech",
          "timer_seconds": 86400,
          "title": "Wait for incubation results"
        },
        {
          "detail": "Did the control indicator show growth as expected, confirming the test kit is viable?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "control-valid",
              "label": "Control grew as expected — test kit is viable"
            },
            {
              "goto": "s10",
              "id": "control-invalid",
              "label": "Control did not grow — test kit result is invalid"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Did the control indicator show growth as expected, confirming the test kit is viable?"
        },
        {
          "detail": "Did the processed test indicator show growth?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-growth",
              "label": "No growth — sterilizer passed"
            },
            {
              "goto": "s11",
              "id": "growth",
              "label": "Growth present — positive spore test"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Did the processed test indicator show growth?"
        },
        {
          "detail": "Record the test date, sterilizer ID, cycle number, lot numbers, control result and test result in the spore test log. Name the corroboration this entry rests on — the test system's own printout, the logbook entry itself, a second person who independently read the indicators, or a photo of the read indicators — and close the entry with an attestation: the role of whoever is vouching for it and the date/time attested. Retain the entry at least the retention period this practice's state dental board requires — no single public-domain source pins an exact number for this log, so treat 3 years as a conservative floor pending counsel/board confirmation, not a fixed statutory figure.\n\nWhy: A weekly test result nobody can corroborate, or that nobody has attested to, is not an audit-grade record — it is a claim.\n\nRecord: Weekly spore test log",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the test"
        },
        {
          "detail": "Hand off the completed weekly log to the compliance officer for the compliance binder or file.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "File with compliance"
        },
        {
          "detail": "Weekly spore test logged",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Weekly spore test logged"
        },
        {
          "detail": "Repeat the test with a new indicator lot. An invalid control means the processed-vial result cannot be trusted either way and does not count as this week's test.\n\nWhy: A non-viable control invalidates the entire test, positive or negative.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Repeat with a new lot",
          "why": "A non-viable control invalidates the entire test, positive or negative."
        },
        {
          "detail": "Quarantine the sterilizer from use, quarantine all loads processed since the last known-negative test, and open the positive spore test response and recall protocol before returning the sterilizer to service.\n\nWhy: A positive spore test means viable spores survived the cycle — the sterilizer cannot be trusted for patient-use instruments until the cause is found and corrected.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Treat as a positive spore test.",
            "role": "compliance officer and dentist or practice owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Treat as a positive spore test",
          "why": "A positive spore test means viable spores survived the cycle — the sterilizer cannot be trusted for patient-use instruments until the cause is found and corrected."
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Weekly biological indicator (spore) test per sterilizer with control and result log — The weekly test day for each sterilizer, every implantable load, and after repair or relocation.",
      "title": "Weekly biological indicator (spore) test per sterilizer with control and result log",
      "trigger": "The weekly test day for each sterilizer, every implantable load, and after repair or relocation",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring; repeat BI testing after a failure)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring; repeat BI testing after a failure)",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — response to a positive biological indicator",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — response to a positive biological indicator",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California 16 CCR §1005 (spore testing and incident recordkeeping)",
          "source": "Dental Board of California 16 CCR §1005 (spore testing and incident recordkeeping)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1005"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 2880,
      "frequency": "as-needed",
      "id": "srm-009",
      "kind": "clinical",
      "materials": [
        "biological indicator test kit with positive control",
        "incubator",
        "sterilization cycle log",
        "\"DO NOT USE\" quarantine tag",
        "sharps-safe transport containers"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "dentist",
        "compliance-officer",
        "practice-owner",
        "all-staff"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "Before anything else: if any patient currently in the office is showing signs of infection, an allergic reaction, uncontrolled bleeding, or another condition needing immediate care, call 911/EMS now. A sterilization monitoring failure by itself is not a medical emergency — it is a quality incident handled by this protocol once no one in the building needs EMS.\n\nWhy: The entry gate exists so a reader never confuses 'a load may not be sterile' with 'someone needs an ambulance' — the two are handled on different clocks.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Rule out an active patient emergency first.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "all-staff",
          "title": "Rule out an active patient emergency first",
          "why": "The entry gate exists so a reader never confuses 'a load may not be sterile' with 'someone needs an ambulance' — the two are handled on different clocks."
        },
        {
          "detail": "Tag the sterilizer \"DO NOT USE\" and remove it from the rotation immediately. Do not run further loads in it until it is cleared by a passing retest.\n\nWhy: Every additional cycle run in a unit that just failed its indicator adds another batch of unverified instruments to the recall list.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Quarantine the implicated sterilizer",
          "why": "Every additional cycle run in a unit that just failed its indicator adds another batch of unverified instruments to the recall list."
        },
        {
          "detail": "Pull the cycle log and list every load run in this sterilizer since the last passing biological, mechanical, and chemical indicator result — cycle number, date, time, contents, and whether it was already released to a treatment room.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "sterilization cycle log"
          ],
          "role": "sterilization-tech",
          "title": "Identify every load released since the last passing indicator"
        },
        {
          "detail": "Run at least 3 biological indicators plus a positive control in the quarantined sterilizer, empty of any patient-ready load, using the manufacturer's standard cycle parameters.\n\nWhy: A single failed spore test is confirmed or ruled out with a repeat test before the unit returns to service — one failure alone does not tell you whether the sterilizer or the indicator was at fault.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "biological indicator test kit with positive control"
          ],
          "role": "sterilization-tech",
          "title": "Run a repeat biological indicator test",
          "why": "A single failed spore test is confirmed or ruled out with a repeat test before the unit returns to service — one failure alone does not tell you whether the sterilizer or the indicator was at fault."
        },
        {
          "detail": "Incubate the test and control biological indicators per the manufacturer's instructions, typically 24–48 hours, and confirm the positive control shows growth (proving the incubator itself works) before reading the test results.",
          "id": "s5",
          "kind": "timer",
          "role": "sterilization-tech",
          "timer_seconds": 86400,
          "title": "Incubate the repeat indicators"
        },
        {
          "detail": "Read all repeat indicators once incubation completes.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "repeat-negative",
              "label": "All repeat indicators are negative"
            },
            {
              "goto": "s11",
              "id": "repeat-positive",
              "label": "One or more repeat indicators is still positive"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Read the repeat test results"
        },
        {
          "detail": "Before returning the unit to routine service, review loading pattern, packaging, cycle selection, and operator technique for what caused the original failure so it does not recur.\n\nWhy: A negative repeat test clears the sterilizer for use, but it does not explain why the first test failed — an unexamined root cause tends to repeat.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Investigate the original failure's root cause",
          "why": "A negative repeat test clears the sterilizer for use, but it does not explain why the first test failed — an unexamined root cause tends to repeat."
        },
        {
          "detail": "Document the original failure, repeat test results, root-cause finding, and the date the unit returned to service in the sterilization log.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the incident resolution"
        },
        {
          "detail": "If operator technique or loading pattern was a factor, hand the finding to the office manager to schedule refresher training for whoever ran the original load.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off to the office manager for retraining if indicated"
        },
        {
          "detail": "Sterilizer cleared and returned to service",
          "id": "s10",
          "kind": "step",
          "title": "Sterilizer cleared and returned to service"
        },
        {
          "detail": "A repeat positive means the recall is confirmed. The dentist, together with the compliance officer, reviews the implicated-load list and decides whether patient notification is warranted per the office's incident policy. This decision is never made by the sterilization technician alone, and it is never auto-generated.\n\nWhy: Whether to notify patients carries clinical, legal, and trust consequences that belong with the licensed provider who owns the patient relationship, not with whoever caught the failed test.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist-led patient-risk review before any notification decision.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist-led patient-risk review before any notification decision",
          "why": "Whether to notify patients carries clinical, legal, and trust consequences that belong with the licensed provider who owns the patient relationship, not with whoever caught the failed test."
        },
        {
          "detail": "For each load on the gathered list, identify which patients received instruments from it and what procedure was performed, so the notification decision is made against a complete picture rather than a partial one.",
          "id": "s12",
          "kind": "step",
          "role": "dentist",
          "title": "Assess patient risk across every implicated load"
        },
        {
          "detail": "Weigh the risk review against the office's incident policy.",
          "forks": [
            {
              "advised": true,
              "goto": "s14",
              "id": "notify-patients",
              "label": "Notify affected patients"
            },
            {
              "goto": "s17",
              "id": "no-notification",
              "label": "Notification is not warranted (e.g., loads never reached a patient, or sterility is no longer in question after root-cause review)"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "dentist",
          "title": "Decide whether affected patients are notified"
        },
        {
          "detail": "Record that notification was initiated through the practice's compliance-approved outreach channel, including the date and who authorized it; message content and delivery are handled outside this log.",
          "id": "s14",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the notification outreach"
        },
        {
          "detail": "The compliance officer files the incident per state dental board recordkeeping requirements and briefs the practice owner; the sterilizer stays quarantined until it independently clears its own repeat-test path.",
          "id": "s15",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hand off to compliance officer and practice owner for regulatory recordkeeping"
        },
        {
          "detail": "Incident closed and logged",
          "id": "s16",
          "kind": "step",
          "title": "Incident closed and logged"
        },
        {
          "detail": "Document the specific reasoning for why notification was not required, tied to the risk review findings.",
          "id": "s17",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the no-notification rationale"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Positive spore test — sterilizer quarantine, repeat test, load recall, patient-risk review and notification decision — A biological indicator shows growth, or a mechanical or chemical indicator fails on a load already released.",
      "title": "Positive spore test — sterilizer quarantine, repeat test, load recall, patient-risk review and notification decision",
      "trigger": "A biological indicator shows growth, or a mechanical or chemical indicator fails on a load already released",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (event-related sterility, storage conditions)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (event-related sterility, storage conditions)",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "srm-010",
      "kind": "clinical",
      "materials": [
        "closed sterile storage cabinet",
        "humidity indicator card",
        "sterilization cycle log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Place cooled, dry, labeled packages in a closed cabinet or drawer away from sinks, floors, and open air traffic.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Store the sterilized package in designated clean storage"
        },
        {
          "detail": "Verify the sterilization date, cycle number, load number, and external chemical indicator color change are all visible on the package before shelving it.\n\nWhy: The label is what lets a recall (srm-009) trace a compromised package back to a specific cycle.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Confirm the package label is complete",
          "why": "The label is what lets a recall (srm-009) trace a compromised package back to a specific cycle."
        },
        {
          "detail": "Keep the storage area dry and enclosed; store packages off the floor and at least a few inches from outer walls; avoid areas near sinks or high dust/traffic zones.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Maintain proper storage conditions"
        },
        {
          "detail": "Place newly sterilized packages behind existing stock so the oldest dated package is used first.\n\nWhy: FIFO rotation keeps any package from sitting long enough that event-related sterility (moisture, handling, shelf wear) becomes a real risk.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Rotate stock first-in, first-out",
          "why": "FIFO rotation keeps any package from sitting long enough that event-related sterility (moisture, handling, shelf wear) becomes a real risk."
        },
        {
          "detail": "Before opening a package chairside, check the wrap for tears, punctures, moisture, or a missing/failed external indicator.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "intact",
              "label": "Package is intact and the indicator shows a pass"
            },
            {
              "goto": "s9",
              "id": "compromised",
              "label": "Package is torn, wet, or the indicator did not change"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "assistant",
          "title": "Inspect package integrity before opening at point of use"
        },
        {
          "detail": "Open using standard aseptic technique so the sterile contents are not touched by an ungloved hand or a non-sterile surface.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Open the package aseptically at chairside"
        },
        {
          "detail": "Note the load number opened against the day's instrument log so it can be traced if needed later.",
          "id": "s7",
          "kind": "step",
          "role": "assistant",
          "title": "Log the load number used"
        },
        {
          "detail": "Package used",
          "id": "s8",
          "kind": "step",
          "title": "Package used"
        },
        {
          "detail": "Do not open or use the package. Set it aside for reprocessing and select an alternate sterile package if the procedure is proceeding.",
          "id": "s9",
          "kind": "step",
          "role": "assistant",
          "title": "Pull the compromised package from use"
        },
        {
          "detail": "Record the load number, the reason it was pulled (torn, wet, failed indicator), and the date.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the compromised package"
        },
        {
          "detail": "Return the compromised package's contents to the dirty side to be cleaned, repackaged, and re-sterilized from the start.",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off to sterilization for reprocessing"
        },
        {
          "detail": "Compromised package removed and queued for reprocessing",
          "id": "s12",
          "kind": "step",
          "title": "Compromised package removed and queued for reprocessing"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Sterile storage, first-in first-out rotation and package integrity check before opening — Packages are stored or retrieved for a procedure; torn or wet packages are reprocessed.",
      "title": "Sterile storage, first-in first-out rotation and package integrity check before opening",
      "trigger": "Packages are stored or retrieved for a procedure; torn or wet packages are reprocessed",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — Immediate Use Steam Sterilization (IUSS)",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — Immediate Use Steam Sterilization (IUSS)",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — IUSS restricted to situations with no alternative",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — IUSS restricted to situations with no alternative",
          "url": "https://www.cdc.gov/dental-infection-control/"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "srm-011",
      "kind": "clinical",
      "materials": [
        "sterilizer with an immediate-use/unwrapped cycle",
        "biological indicator (for implant-related use)",
        "sterile transport tray"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check for a second sterile copy of the needed instrument before considering immediate-use sterilization.\n\nWhy: Immediate-use sterilization skips the drying and cooling steps of a routine cycle and is restricted to situations where no alternative exists — it is not a convenience shortcut.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Confirm no sterile duplicate is available",
          "why": "Immediate-use sterilization skips the drying and cooling steps of a routine cycle and is restricted to situations where no alternative exists — it is not a convenience shortcut."
        },
        {
          "detail": "The dentist reviews and authorizes the immediate-use exception before the cycle is run; the reason is recorded, not assumed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist authorizes the immediate-use exception.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist authorizes the immediate-use exception"
        },
        {
          "detail": "Set the sterilizer to the manufacturer-specified immediate-use cycle time, temperature, and pressure for the instrument type.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Select the correct unwrapped cycle parameters"
        },
        {
          "detail": "Run the cycle to completion and confirm the mechanical and chemical indicators both pass before removing the instrument.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Run the cycle and verify indicators"
        },
        {
          "detail": "Implant cases carry a higher bar because there is no second chance to verify sterility after placement.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "not-implant",
              "label": "Not an implant case"
            },
            {
              "goto": "s10",
              "id": "implant-case",
              "label": "Implant placement"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this instrument for implant placement?"
        },
        {
          "detail": "Carry the instrument directly to the operatory on a sterile field. Do not set it down on an unprotected surface or allow it to cool exposed to open air.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Transport the instrument aseptically to point of use"
        },
        {
          "detail": "Record the instrument, cycle parameters, date, and the reason no sterile duplicate was available.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the immediate-use sterilization event"
        },
        {
          "detail": "IUSS is for one instrument at a time when no alternative exists — not for routine convenience, not for storing the item wrapped afterward, and not a substitute for maintaining adequate instrument inventory.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Confirm restriction reminders for next time"
        },
        {
          "detail": "Instrument used and event logged",
          "id": "s9",
          "kind": "step",
          "title": "Instrument used and event logged"
        },
        {
          "detail": "Run a biological indicator alongside the instrument. CDC guidance discourages IUSS for implantable devices without a BI in the same load, because there is no recall opportunity once the item is placed.\n\nWhy: Implant cases have no opportunity to recall the item after placement, so the extra monitoring step exists specifically for this scenario.",
          "id": "s10",
          "kind": "step",
          "role": "dentist",
          "title": "Place a biological indicator in the same cycle for an implant case",
          "why": "Implant cases have no opportunity to recall the item after placement, so the extra monitoring step exists specifically for this scenario."
        },
        {
          "detail": "If the BI result is not available before placement, the dentist must explicitly authorize proceeding on this specific implant case — a separate decision from the general immediate-use authorization given earlier, because CDC guidance discourages IUSS for implantable devices absent a read biological indicator. If the dentist instead elects to wait for the BI result, placement is delayed until it reads.\n\nWhy: The earlier authorization approved skipping a duplicate instrument, not skipping the implant-specific BI wait; this gate makes that a distinct, logged clinical judgment.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist explicitly signs off on proceeding without a read BI result.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist explicitly signs off on proceeding without a read BI result",
          "why": "The earlier authorization approved skipping a duplicate instrument, not skipping the implant-specific BI wait; this gate makes that a distinct, logged clinical judgment."
        },
        {
          "detail": "Document that a BI was placed, whether the result was available before placement, and the dentist's rationale if placement proceeded without waiting.",
          "id": "s12",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the implant-case rationale"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Immediate-use sterilization — restricted use and documentation — A single instrument is needed urgently and no sterile duplicate exists.",
      "title": "Immediate-use sterilization — restricted use and documentation",
      "trigger": "A single instrument is needed urgently and no sterile duplicate exists",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — routine maintenance and post-repair validation with consecutive BI cycles",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — routine maintenance and post-repair validation with consecutive BI cycles",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        },
        {
          "kind": "regulation",
          "label": "FDA-cleared sterilizer labeling and maintenance instructions — 21 CFR 880.6880 (steam sterilizer device classification)",
          "source": "FDA-cleared sterilizer labeling and maintenance instructions — 21 CFR 880.6880 (steam sterilizer device classification)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-880/subpart-G/section-880.6880"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 15,
      "frequency": "daily",
      "id": "srm-012",
      "kind": "clinical",
      "materials": [
        "manufacturer maintenance manual",
        "distilled water reservoir",
        "biological indicator test kit",
        "sterilizer maintenance log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "office-manager",
        "it-vendor"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Work the daily, weekly, and monthly maintenance items in order for every sterilizer in the office, not just the one in active use.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Follow the maintenance schedule for each sterilizer"
        },
        {
          "detail": "Wipe and inspect the chamber, check door gaskets and seals for damage, check and refill the distilled water reservoir, and log completion.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Complete daily maintenance"
        },
        {
          "detail": "Run the weekly biological indicator test for each sterilizer (srm-008), and perform any manufacturer-specified weekly cleaning or descaling.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Complete weekly maintenance"
        },
        {
          "detail": "Inspect gaskets and seals for wear, verify pressure and temperature calibration per the manufacturer manual, and review the log for completeness and missed entries.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Complete monthly maintenance"
        },
        {
          "detail": "A unit that has been opened, repaired, or relocated needs to prove itself again before trusted with a patient load.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "not-repaired",
              "label": "No service or repair since last cycle"
            },
            {
              "goto": "s8",
              "id": "was-repaired",
              "label": "Serviced, repaired, or relocated"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Was this sterilizer serviced or repaired since its last completed cycle?"
        },
        {
          "detail": "Record the date, technician initials, and tasks completed in the sterilizer maintenance log.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log routine maintenance"
        },
        {
          "detail": "Routine maintenance logged",
          "id": "s7",
          "kind": "step",
          "title": "Routine maintenance logged"
        },
        {
          "detail": "Run 3 consecutive empty cycles, each with a biological indicator, and do not release any patient load until all 3 pass.\n\nWhy: A unit coming back from repair or relocation has an unknown state until it proves sterilization performance across multiple consecutive cycles, not just one.",
          "id": "s8",
          "kind": "step",
          "materials": [
            "biological indicator test kit"
          ],
          "role": "sterilization-tech",
          "title": "Run post-repair validation before returning the unit to service",
          "why": "A unit coming back from repair or relocation has an unknown state until it proves sterilization performance across multiple consecutive cycles, not just one."
        },
        {
          "detail": "Record the repair or service performed, the vendor, and the results of all 3 validation cycles with dates.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the post-repair validation results"
        },
        {
          "detail": "Notify the office manager once validation passes so the unit can be scheduled back into rotation.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand off to office manager confirming the unit is cleared"
        },
        {
          "detail": "Sterilizer validated and returned to service",
          "id": "s11",
          "kind": "step",
          "title": "Sterilizer validated and returned to service"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Sterilizer daily, weekly and monthly maintenance and post-repair validation — The maintenance schedule is due or the unit was serviced.",
      "title": "Sterilizer daily, weekly and monthly maintenance and post-repair validation",
      "trigger": "The maintenance schedule is due or the unit was serviced",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilization capacity as a condition of safe treatment",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — sterilization capacity as a condition of safe treatment",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "generic",
          "label": "For equipment-outage contingency staffing and scheduling — no vendor-specific troubleshooting reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for equipment-outage contingency staffing and scheduling — no vendor-specific troubleshooting reproduced"
          },
          "source": "For equipment-outage contingency staffing and scheduling — no vendor-specific troubleshooting reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 45,
      "frequency": "as-needed",
      "id": "srm-013",
      "kind": "clinical",
      "materials": [
        "manufacturer troubleshooting guide",
        "service vendor contact list",
        "backup sterilizer or off-site reprocessing arrangement (if available)",
        "day schedule"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "office-manager",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Note the error code or symptom shown on the sterilizer display, and whether the cycle aborted mid-run or the unit would not start at all.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Identify the fault or error condition"
        },
        {
          "detail": "Check the troubleshooting guide for this specific error code before attempting anything.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "safe-reset",
              "label": "A manufacturer-listed safe reset applies"
            },
            {
              "goto": "s7",
              "id": "hazard-condition",
              "label": "The fault indicates a hazard condition (steam or pressure fault, visible leak)"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Is a manufacturer-listed safe reset available for this fault?"
        },
        {
          "detail": "Perform the single manufacturer-listed reset step. Do not repeatedly power-cycle or attempt undocumented fixes.\n\nWhy: Repeated ad-hoc resets on a faulting pressure vessel are a safety risk in themselves, not just a troubleshooting inconvenience.",
          "id": "s3",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Attempt the one listed reset",
          "why": "Repeated ad-hoc resets on a faulting pressure vessel are a safety risk in themselves, not just a troubleshooting inconvenience."
        },
        {
          "detail": "Did the reset resolve the fault?",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "resolved",
              "label": "Fault cleared, cycle runs normally"
            },
            {
              "goto": "s7",
              "id": "not-resolved",
              "label": "Fault persists"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Did the reset resolve the fault?"
        },
        {
          "detail": "Record the error code, the reset performed, and the time to resolution in the maintenance log.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the fault and resolution"
        },
        {
          "detail": "Sterilizer back in normal rotation",
          "id": "s6",
          "kind": "step",
          "title": "Sterilizer back in normal rotation"
        },
        {
          "detail": "Tag the sterilizer \"DO NOT USE\" and stop attempting fixes beyond the one listed safe reset.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Take the unit out of service"
        },
        {
          "detail": "Hand off to the office's equipment service vendor with the error code and symptom description to schedule a repair.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Contact the service vendor for repair"
        },
        {
          "detail": "Is a backup sterilizer or off-site reprocessing arrangement available?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "backup-available",
              "label": "A second in-house sterilizer or off-site arrangement is available"
            },
            {
              "goto": "s13",
              "id": "no-backup",
              "label": "No backup capacity available today"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is a backup sterilizer or off-site reprocessing arrangement available?"
        },
        {
          "detail": "Run all pending loads through the backup sterilizer or off-site arrangement, applying the same monitoring requirements as the primary unit.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Reroute today's loads to backup capacity"
        },
        {
          "detail": "Record which loads ran on the backup unit and confirm indicator results for each.",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the rerouted loads"
        },
        {
          "detail": "Loads processed on backup capacity, primary unit awaiting repair",
          "id": "s12",
          "kind": "step",
          "title": "Loads processed on backup capacity, primary unit awaiting repair"
        },
        {
          "detail": "The office manager and dentist review the day's remaining appointments together and identify which need rescheduling versus which can proceed with the existing sterile inventory on hand.\n\nWhy: Without sterilization capacity, some procedures genuinely cannot proceed safely today — this is a scheduling and clinical judgment call made jointly, not a unilateral front-desk decision.",
          "id": "s13",
          "kind": "step",
          "role": "office-manager",
          "title": "Review today's schedule for procedures needing instruments that can't be reprocessed in time",
          "why": "Without sterilization capacity, some procedures genuinely cannot proceed safely today — this is a scheduling and clinical judgment call made jointly, not a unilateral front-desk decision."
        },
        {
          "detail": "Before any appointment proceeds or is rescheduled, the dentist and office manager jointly confirm the decision for each affected appointment — no procedure needing instruments that cannot be reprocessed in time proceeds on a front-desk decision alone.\n\nWhy: This gate structurally enforces the joint clinical/scheduling call described above rather than leaving it to prose alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist and office manager jointly sign off on which appointments proceed.",
            "role": "dentist and office manager",
            "type": "licensed"
          },
          "id": "s14",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist and office manager jointly sign off on which appointments proceed",
          "why": "This gate structurally enforces the joint clinical/scheduling call described above rather than leaving it to prose alone."
        },
        {
          "detail": "Record which appointments were rescheduled and why, tied to the sterilizer outage.",
          "id": "s15",
          "kind": "step",
          "role": "office-manager",
          "title": "Log the schedule adjustments"
        },
        {
          "detail": "Schedule adjusted to match available sterile capacity",
          "id": "s16",
          "kind": "step",
          "title": "Schedule adjusted to match available sterile capacity"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Sterilizer fault or aborted cycle mid-day — contingency instrument supply and cycle rerouting — The sterilizer errors, aborts or will not start with patients scheduled.",
      "title": "Sterilizer fault or aborted cycle mid-day — contingency instrument supply and cycle rerouting",
      "trigger": "The sterilizer errors, aborts or will not start with patients scheduled",
      "trigger_kind": "incident",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — single-use (disposable) devices are used on one patient and discarded",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — single-use (disposable) devices are used on one patient and discarded",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "regulation",
          "label": "FDA single-use device labeling requirement (do-not-reuse symbol, 21 CFR 801.15 general labeling)",
          "source": "FDA single-use device labeling requirement (do-not-reuse symbol, 21 CFR 801.15 general labeling)"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 5,
      "frequency": "per-use",
      "id": "srm-014",
      "kind": "clinical",
      "materials": [
        "single-use item symbol reference sheet",
        "labeled waste receptacles",
        "single-use item stock log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "sterilization-tech",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Check packaging for the \"do not reuse\" symbol (a crossed-out numeral 2) before setting up a tray.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Recognize the single-use marking"
        },
        {
          "detail": "Common single-use items include saliva ejectors, prophy angles, disposable air/water syringe tips, anesthetic needles, and disposable impression trays where stocked — confirm against the office's current supply list, since disposable-vs-reusable varies by what is stocked.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Know this office's single-use items"
        },
        {
          "detail": "Was a single-use item found reused or reprocessed?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "normal-use",
              "label": "Normal single use, ready to discard"
            },
            {
              "goto": "s6",
              "id": "found-reused",
              "label": "A single-use item was found reprocessed or reused"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Was a single-use item found reused or reprocessed?"
        },
        {
          "detail": "Place the item in the appropriate labeled waste stream (regulated medical waste or sharps container as applicable) immediately after the single use.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Discard immediately after use"
        },
        {
          "detail": "Item discarded correctly",
          "id": "s5",
          "kind": "step",
          "title": "Item discarded correctly"
        },
        {
          "detail": "A reused single-use item is a compliance finding, not a routine correction — the compliance officer reviews it before the tray is used and before anything is discarded that might be needed for the review.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer reviews the finding.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer reviews the finding"
        },
        {
          "detail": "Pull the item from the tray and set aside; substitute a genuinely single-use replacement before the tray is used.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Remove the item from circulation"
        },
        {
          "detail": "Check whether the cause was mislabeled stock, a supply substitution that removed a disposable's markings, or a staff training gap.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Determine the root cause"
        },
        {
          "detail": "Record the item, the finding, the root cause, and the corrective action in the compliance log.",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the finding"
        },
        {
          "detail": "Hand the finding to the office manager to schedule a single-use policy refresher for the staff involved.",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hand off to office manager for retraining"
        },
        {
          "detail": "Finding closed, corrective action assigned",
          "id": "s11",
          "kind": "step",
          "title": "Finding closed, corrective action assigned"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Single-use device policy — identify, discard, stock and prevent reuse — A reused single-use item is found in a tray setup, or supply substitution introduces a new disposable.",
      "title": "Single-use device policy — identify, discard, stock and prevent reuse",
      "trigger": "A reused single-use item is found in a tray setup, or supply substitution introduces a new disposable",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — Spaulding classification, semi-critical items and high-level disinfection",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — Spaulding classification, semi-critical items and high-level disinfection",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "srm-015",
      "kind": "clinical",
      "materials": [
        "FDA-cleared high-level disinfectant solution",
        "manufacturer chemical test strips",
        "immersion basin with lid",
        "rinse water per label instructions"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Confirm the item contacts mucous membranes or non-intact skin (semi-critical, per Spaulding classification) and cannot tolerate an autoclave cycle.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Identify the item as heat-sensitive and semi-critical"
        },
        {
          "detail": "Clean visible debris from the item per the manufacturer's instructions before immersion — disinfectant cannot reach a surface that is still soiled.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Pre-clean the item"
        },
        {
          "detail": "Mix or verify the FDA-cleared high-level disinfectant to the concentration on its label, and confirm potency with a manufacturer test strip before use.",
          "id": "s3",
          "kind": "step",
          "materials": [
            "FDA-cleared high-level disinfectant solution",
            "manufacturer chemical test strips"
          ],
          "role": "sterilization-tech",
          "title": "Prepare the disinfectant solution to labeled concentration"
        },
        {
          "detail": "Fully immerse the item, cover the basin, and hold for the exact contact time on this office's specific product label — high-level disinfectant contact times commonly range 12 to 90 minutes by product, so read the label rather than assuming a fixed number.\n\nCadence: an unspecified interval (no valid timer duration in source — downgraded from a timer step).",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Immerse for label-specified contact time (typically 12-90 min — see product label)"
        },
        {
          "detail": "Rinse with the water type specified on the disinfectant label (sterile or filtered where required) to remove chemical residue before the item touches a patient.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Rinse the item per label instructions"
        },
        {
          "detail": "Dry the item and store it covered and labeled with the date and time of disinfection, separate from contaminated instruments.",
          "id": "s6",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Dry and store to prevent recontamination"
        },
        {
          "detail": "Test solution potency with a chemical indicator strip before each day's first use, and track the solution's reuse life and expiration per the product label.",
          "id": "s7",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Manage the disinfectant solution"
        },
        {
          "detail": "Record the item, date, contact time, test-strip result, and operator initials in the HLD log.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the HLD cycle"
        },
        {
          "detail": "Item high-level disinfected and stored",
          "id": "s9",
          "kind": "step",
          "title": "Item high-level disinfected and stored"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "High-level disinfection of heat-sensitive semi-critical items — A reusable item cannot be heat sterilized.",
      "title": "High-level disinfection of heat-sensitive semi-critical items",
      "trigger": "A reusable item cannot be heat sterilized",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings — instruments inspected for damage, corrosion, and functionality and removed from service before packaging for sterilization",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings — instruments inspected for damage, corrosion, and functionality and removed from service before packaging for sterilization",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "generic",
          "label": "For instrument inventory management and sharpening cadence — no vendor sharpening system reproduced — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic functional equivalent for instrument inventory management and sharpening cadence — no vendor sharpening system reproduced"
          },
          "source": "For instrument inventory management and sharpening cadence — no vendor sharpening system reproduced — Practice policy — no published authority governs this step."
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 90,
      "frequency": "monthly",
      "id": "srm-016",
      "kind": "clinical",
      "materials": [
        "full instrument set inventory list",
        "sharpening stone or in-house sharpening equipment",
        "test stick for edge verification",
        "instrument inventory log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Pull every full instrument set out of rotation for inspection on the scheduled audit day.",
          "id": "s1",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Begin the monthly instrument audit"
        },
        {
          "detail": "Check each instrument for corrosion, pitting, dulled or chipped edges, handle scoring, and hinge or joint looseness.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Inspect each instrument"
        },
        {
          "detail": "Is the instrument still functional and safe?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "keep-in-service",
              "label": "Functional and safe"
            },
            {
              "goto": "s6",
              "id": "retire-candidate",
              "label": "Damaged, corroded, or unsafe to use"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Is the instrument still functional and safe?"
        },
        {
          "detail": "Record the instrument as inspected and returned to circulation with the audit date.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the inspection pass"
        },
        {
          "detail": "Instrument returned to service",
          "id": "s5",
          "kind": "step",
          "title": "Instrument returned to service"
        },
        {
          "detail": "Edged instruments like scalers and curettes are usually sharpenable; instruments with structural damage (cracked handles, sprung hinges, broken tips) are not.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "sharpen-it",
              "label": "Sharpenable — restore the edge"
            },
            {
              "goto": "s10",
              "id": "discard-it",
              "label": "Structurally damaged — must be discarded"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Is the instrument sharpenable, or must it be discarded?"
        },
        {
          "detail": "Sharpen using the office's in-house stone or sharpening equipment, then verify the edge with a test stick before returning the instrument to a set.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "sharpening stone or in-house sharpening equipment",
            "test stick for edge verification"
          ],
          "role": "sterilization-tech",
          "title": "Sharpen the instrument"
        },
        {
          "detail": "Record the instrument, date sharpened, and edge verification result in the inventory log.",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the sharpening"
        },
        {
          "detail": "Instrument sharpened and returned to service",
          "id": "s9",
          "kind": "step",
          "title": "Instrument sharpened and returned to service"
        },
        {
          "detail": "Remove the instrument from the inventory count and dispose of it appropriately (sharps container for pointed/edged instruments).",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Remove and dispose of the instrument"
        },
        {
          "detail": "Record the instrument, reason for retirement, and date removed from inventory, and flag it for reorder if the set needs replacement.",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the retirement"
        },
        {
          "detail": "Instrument retired from inventory",
          "id": "s12",
          "kind": "step",
          "title": "Instrument retired from inventory"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Instrument inventory, retirement and sharpening schedule — The monthly instrument audit day arrives, or a dull or damaged instrument is found at inspection.",
      "title": "Instrument inventory, retirement and sharpening schedule",
      "trigger": "The monthly instrument audit day arrives, or a dull or damaged instrument is found at inspection",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings (sterilization monitoring: mechanical, chemical, biological weekly)",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        },
        {
          "kind": "regulation",
          "label": "FDA device classification — Sterilization wrap (21 CFR 880.6850)",
          "source": "FDA device classification — Sterilization wrap (21 CFR 880.6850)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-880/subpart-G/section-880.6850"
        },
        {
          "kind": "regulation",
          "label": "FDA device classification — Sterilization process indicator (21 CFR 880.2800)",
          "source": "FDA device classification — Sterilization process indicator (21 CFR 880.2800)",
          "url": "https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-880/subpart-C/section-880.2800"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "source": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1005"
        },
        {
          "kind": "generic",
          "label": "Generic practice policy: a loaner kit is treated as contaminated/unverified until the practice's own reprocessing and indicator cycle clears it — no manufacturer sterility claim is accepted at face value — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "Generic practice policy: a loaner kit is treated as contaminated/unverified until the practice's own reprocessing and indicator cycle clears it — no manufacturer sterility claim is accepted at face value"
          },
          "source": "Generic practice policy: a loaner kit is treated as contaminated/unverified until the practice's own reprocessing and indicator cycle clears it — no manufacturer sterility claim is accepted at face value — Practice policy — no published authority governs this step."
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 60,
      "frequency": "as-needed",
      "id": "srm-017",
      "kind": "clinical",
      "materials": [
        "loaner kit shipping case and manifest/instrument count sheet",
        "cleaning and reprocessing supplies (enzymatic solution, ultrasonic or washer-disinfector)",
        "sterilization pouches/wrap and chemical + biological indicators",
        "return shipping label and case",
        "loaner tracking log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "sterilization-tech",
        "assistant",
        "dentist"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "When the kit case arrives, check it against the schedule to confirm it is for tomorrow's (or later) surgical case and that there is enough time before the case start to fully reprocess it.\n\nWhy: A loaner that arrives too close to the case time cannot be safely reprocessed and released in time — this must surface early enough to reschedule if needed.",
          "id": "s1",
          "kind": "step",
          "role": "assistant",
          "title": "Confirm the loaner kit arrival against the surgical schedule",
          "why": "A loaner that arrives too close to the case time cannot be safely reprocessed and released in time — this must surface early enough to reschedule if needed."
        },
        {
          "detail": "Open the case and count every instrument and tray insert against the printed manifest/count sheet included with the kit. Note any missing, damaged, or extra items.\n\nWhy: A count mismatch discovered mid-surgery is unrecoverable — it must be caught and resolved before the kit is reprocessed.",
          "id": "s2",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Verify instrument count against the manufacturer's manifest",
          "why": "A count mismatch discovered mid-surgery is unrecoverable — it must be caught and resolved before the kit is reprocessed."
        },
        {
          "detail": "Does the count and condition match the manifest?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "match",
              "label": "Count matches, no damage"
            },
            {
              "goto": "s14",
              "id": "mismatch",
              "label": "Missing, damaged, or extra items found"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "sterilization-tech",
          "title": "Does the count and condition match the manifest?"
        },
        {
          "detail": "Never treat a loaner kit as pre-sterile even if labeled 'sterile' or 'cleaned' by the vendor. Disassemble, clean (ultrasonic or washer-disinfector), rinse, and visually inspect every instrument per the practice's standard cleaning protocol.\n\nWhy: Transit and prior use at other practices means the practice's own indicator-verified cycle is the only sterility assurance it controls.",
          "id": "s4",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Treat the kit as contaminated regardless of vendor claims",
          "why": "Transit and prior use at other practices means the practice's own indicator-verified cycle is the only sterility assurance it controls."
        },
        {
          "detail": "Package each instrument or tray in appropriate wrap or pouches, placing an internal chemical indicator with each package and an external indicator or indicator tape on the outside; label with the load date and intended case.",
          "id": "s5",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Package with internal and external chemical indicators"
        },
        {
          "detail": "Load the sterilizer per the manufacturer's cycle for the tray/wrap type used and run the complete cycle; do not shorten a flash/rapid cycle to meet a time crunch.\n\nWhy: Cutting cycle time to make a case deadline defeats the purpose of the reprocessing step this protocol exists to enforce.",
          "id": "s6",
          "kind": "timer",
          "role": "sterilization-tech",
          "timer_seconds": 1800,
          "title": "Run the full sterilization cycle",
          "why": "Cutting cycle time to make a case deadline defeats the purpose of the reprocessing step this protocol exists to enforce."
        },
        {
          "detail": "The dentist confirms the chemical indicators passed and the load is complete before the kit leaves the sterile-storage area for the case — this sign-off is not delegated to the sterilization tech, given the implant/surgical stakes of a loaner kit.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before the kit is released to the operatory.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before the kit is released to the operatory"
        },
        {
          "detail": "Record the cycle number, date, indicator results, and releasing staff initials against the loaner kit ID in the sterilization log and the loaner tracking log.\n\nRecord: Daily sterilization log and loaner tracking log",
          "id": "s8",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the reprocessing cycle and release"
        },
        {
          "detail": "Deliver the sterile, released kit to the assistant setting up the case, confirming the count one more time at handoff.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Hand the sterile kit off to the operatory team"
        },
        {
          "detail": "Once the case is complete, the kit goes through the full clean-package-sterilize cycle again — the same as any other used instrument set — before it is boxed for return.\n\nWhy: The kit must never be shipped back to the vendor, or to another practice, in a used/contaminated state.",
          "id": "s10",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "After the case: reprocess again before return",
          "why": "The kit must never be shipped back to the vendor, or to another practice, in a used/contaminated state."
        },
        {
          "detail": "Re-count every instrument and insert against the original manifest before closing the case for return shipping; note and resolve any discrepancy with the vendor before the case ships.",
          "id": "s11",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Verify count before return shipment"
        },
        {
          "detail": "Record the return ship date, tracking number, and confirming staff initials in the loaner tracking log.\n\nRecord: Loaner tracking log",
          "id": "s12",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Log the return"
        },
        {
          "detail": "Loaner kit reprocessed, used, and returned",
          "id": "s13",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Loaner kit reprocessed, used, and returned"
        },
        {
          "detail": "Call the vendor's loaner coordination line to report the discrepancy and confirm whether the case can still proceed with the kit as received. Notify the dentist of record immediately.\n\nWhy: The surgeon needs to know before the case whether a required instrument is missing so the case can be rescheduled or a substitute sourced.",
          "id": "s14",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Contact the vendor and flag the case",
          "why": "The surgeon needs to know before the case whether a required instrument is missing so the case can be rescheduled or a substitute sourced."
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Vendor loaner surgical kit receipt, reprocessing before use and return — An implant or surgical kit arrives on loan from a manufacturer the day before surgery.",
      "title": "Vendor loaner surgical kit receipt, reprocessing before use and return",
      "trigger": "An implant or surgical kit arrives on loan from a manufacturer the day before surgery",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "public_domain",
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "source": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "url": "https://www.cdc.gov/dental-infection-control/"
        },
        {
          "kind": "public_domain",
          "label": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — reprocessing considerations for suspected/confirmed Creutzfeldt-Jakob disease and other prion diseases",
          "source": "CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) — reprocessing considerations for suspected/confirmed Creutzfeldt-Jakob disease and other prion diseases",
          "url": "https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html"
        },
        {
          "kind": "regulation",
          "label": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "source": "Dental Board of California 16 CCR §1005 (weekly spore testing, logs)",
          "url": "https://www.law.cornell.edu/regulations/california/16-CCR-1005"
        },
        {
          "kind": "generic",
          "label": "Generic practice policy: routine steam sterilization is not validated against prion agents; the practice's own decision tree (single-use, quarantine, or referral) fills the gap the public floor leaves open",
          "source": "Generic practice policy: routine steam sterilization is not validated against prion agents; the practice's own decision tree (single-use, quarantine, or referral) fills the gap the public floor leaves open"
        }
      ],
      "class": "sterilization-infection-control",
      "department": "clinical",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "srm-018",
      "kind": "clinical",
      "materials": [
        "health history intake form",
        "single-use/disposable instrument options where available",
        "quarantine container and label for held instruments",
        "reference contact for the state or local health department"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "sterilization-tech",
        "compliance-officer",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "When the health history form lists a personal or family history of Creutzfeldt-Jakob disease (CJD) or another prion disease, the reviewing staff member flags the chart before any instruments are prepared for the visit.\n\nWhy: The decision about instrument handling has to be made before setup, not discovered chairside.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Flag the history entry at intake review",
          "why": "The decision about instrument handling has to be made before setup, not discovered chairside."
        },
        {
          "detail": "The dentist reviews the flagged history personally and confirms with the patient (or record) whether the diagnosis is personal, family, or unconfirmed, before any procedure is scheduled or instruments are pulled.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off on the flagged history before scheduling proceeds.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s2",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off on the flagged history before scheduling proceeds"
        },
        {
          "detail": "Is this a confirmed or strongly suspected personal diagnosis of CJD or another prion disease?",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "confirmed",
              "label": "Confirmed or strongly suspected personal diagnosis"
            },
            {
              "goto": "s8",
              "id": "family-only",
              "label": "Family history only, patient not diagnosed"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is this a confirmed or strongly suspected personal diagnosis of CJD or another prion disease?"
        },
        {
          "detail": "Substitute disposable instruments for every item where a single-use option exists (e.g. disposable mirrors, disposable prophy angles, disposable saliva ejectors); document the substitution.\n\nWhy: Routine steam sterilization is not validated to inactivate prion agents, so avoiding reusable-instrument contact is the most reliable control available in an office setting.",
          "id": "s4",
          "kind": "step",
          "role": "assistant",
          "title": "Use single-use/disposable instruments wherever the procedure allows",
          "why": "Routine steam sterilization is not validated to inactivate prion agents, so avoiding reusable-instrument contact is the most reliable control available in an office setting."
        },
        {
          "detail": "Can the planned procedure be completed using only single-use instruments?",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "yes-single-use",
              "label": "Yes — the procedure can be done entirely with disposables"
            },
            {
              "goto": "s9",
              "id": "no-reusable-needed",
              "label": "No — a reusable critical instrument is required"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Can the planned procedure be completed using only single-use instruments?"
        },
        {
          "detail": "Complete the visit using only single-use items; dispose of all used items as regulated biohazard waste rather than sending anything to the sterilization area.",
          "id": "s6",
          "kind": "step",
          "role": "assistant",
          "title": "Complete the procedure and dispose of instruments as biohazard waste"
        },
        {
          "detail": "Instrument-handling decision resolved for this patient",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Instrument-handling decision resolved for this patient"
        },
        {
          "detail": "Document that the flag was a family history only, with no personal diagnosis confirmed, and proceed with the practice's standard infection-control protocol for the visit.\n\nWhy: A family history alone does not meet the threshold the public guidance sets for special handling — over-flagging every family history would make the special-handling pathway meaningless.",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Note family history and proceed with standard precautions",
          "why": "A family history alone does not meet the threshold the public guidance sets for special handling — over-flagging every family history would make the special-handling pathway meaningless."
        },
        {
          "detail": "If a reusable critical instrument cannot be avoided, quarantine it after use in a separately labeled, sealed container — do not return it to general circulation or the routine sterilization workflow — and contact the state or local health department or a referral center for prion-specific reprocessing or disposal guidance before any further action.\n\nWhy: Routine sterilization does not clear the practice to reuse the instrument on the next patient; the decision on reprocessing or disposal belongs to public-health/specialist guidance, not the practice alone.",
          "id": "s9",
          "kind": "step",
          "role": "sterilization-tech",
          "title": "Quarantine any reusable instrument that must be used",
          "why": "Routine sterilization does not clear the practice to reuse the instrument on the next patient; the decision on reprocessing or disposal belongs to public-health/specialist guidance, not the practice alone."
        },
        {
          "detail": "Record which instrument was quarantined, the container label, the date, and the name/reference of the health department or referral contact reached, in the sterilization log and the patient's chart.\n\nRecord: Sterilization log and patient chart entry (diagnosis-adjacent — PHI, on-device only)",
          "id": "s10",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Document the quarantine and outside contact"
        },
        {
          "detail": "The compliance officer takes ownership of tracking the outside guidance response and closing out the quarantine hold once instructions are received.",
          "id": "s11",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Hand off to the compliance officer for follow-up"
        }
      ],
      "subclass": "sterilization-and-instrument-reprocessing",
      "summary": "Suspected prion disease patient: instrument handling decision — A patient's history lists Creutzfeldt-Jakob disease or a family member with prion disease.",
      "title": "Suspected prion disease patient: instrument handling decision",
      "trigger": "A patient's history lists Creutzfeldt-Jakob disease or a family member with prion disease",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "label": "CDC Guidelines for Infection Control in Dental Health-Care Settings",
          "source": "Centers for Disease Control and Prevention",
          "url": "https://www.cdc.gov/oral-health/hcp/infection-control/index.html"
        },
        {
          "label": "OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030",
          "source": "Occupational Safety and Health Administration",
          "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030"
        },
        {
          "label": "CDC Summary of Infection Prevention Practices in Dental Settings",
          "source": "Centers for Disease Control and Prevention",
          "url": "https://www.cdc.gov/oral-health/hcp/infection-control/summary.html"
        }
      ],
      "class": "sterilization-infection-control",
      "id": "steril-instrument-reprocessing-cycle-protocol",
      "kind": "clinical",
      "review_status": "draft_unreviewed",
      "roles": [
        "assistant",
        "hygienist",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "steps": [
        {
          "detail": "Carry used instruments from the operatory to the instrument-processing area in a covered, puncture-resistant, leakproof container. Do not carry loose or uncovered instruments through patient-care or common areas.",
          "id": "s1",
          "kind": "step",
          "materials": [
            "covered transport container",
            "utility gloves"
          ],
          "role": "assistant",
          "title": "Transport contaminated instruments"
        },
        {
          "detail": "If instruments cannot be cleaned right away, place them in a labeled holding solution or an enzymatic pre-soak to prevent bioburden from drying onto the surface. Do not let contaminated instruments sit dry and uncovered.",
          "id": "s2",
          "kind": "step",
          "materials": [
            "enzymatic pre-soak solution",
            "labeled holding tray"
          ],
          "role": "assistant",
          "title": "Hold or pre-soak if cleaning is delayed"
        },
        {
          "detail": "Decide whether instruments go through the ultrasonic cleaner or a washer-disinfector based on what the practice has available and the manufacturer's load guidance. Both are acceptable mechanical cleaning methods; hand-scrubbing contaminated instruments is avoided whenever a mechanical method is available.",
          "forks": [
            {
              "goto": "s4",
              "id": "ultrasonic",
              "label": "Ultrasonic cleaner"
            },
            {
              "goto": "s5",
              "id": "washer-disinfector",
              "label": "Washer-disinfector"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "assistant",
          "title": "Choose the cleaning method"
        },
        {
          "detail": "Fully submerge instruments, open hinged instruments, and run a complete ultrasonic cycle per the unit's manufacturer instructions. Rinse instruments with water after the cycle to remove residual cleaning solution before packaging.",
          "id": "s4",
          "kind": "step",
          "materials": [
            "ultrasonic cleaner",
            "ultrasonic solution",
            "rinse basin"
          ],
          "role": "assistant",
          "title": "Run the ultrasonic cleaner"
        },
        {
          "detail": "Load instruments into the washer-disinfector per the unit's rack instructions, open hinged instruments, and run the standard wash/thermal-disinfection cycle per manufacturer instructions.",
          "id": "s5",
          "kind": "step",
          "materials": [
            "washer-disinfector",
            "instrument racks"
          ],
          "role": "assistant",
          "title": "Run the washer-disinfector"
        },
        {
          "detail": "Under good lighting, and magnification if available, check every instrument for visible debris, residual bioburden, corrosion, or damage. Send anything still visibly soiled back through cleaning; set aside anything damaged rather than packaging it.",
          "id": "s6",
          "kind": "step",
          "materials": [
            "magnifying lamp"
          ],
          "role": "assistant",
          "title": "Inspect each instrument before packaging"
        },
        {
          "detail": "Place cleaned, dry instruments into sterilization pouches or wrap, with an internal chemical indicator inside each package and an external indicator visible on the outside. Do not overload a pouch beyond what allows the sterilant to reach every surface.",
          "id": "s7",
          "kind": "step",
          "materials": [
            "sterilization pouches or wrap",
            "internal chemical indicator strips",
            "external indicator tape"
          ],
          "role": "assistant",
          "title": "Package with a chemical indicator"
        },
        {
          "detail": "Most instruments are wrapped and stored sterile until use. A small set may be processed unwrapped for immediate use only when a wrapped, sterile set is genuinely not available and the item will be used before it cools or is set down — unwrapped items are not stored for later use.",
          "forks": [
            {
              "goto": "s9",
              "id": "wrapped",
              "label": "Wrapped for storage"
            },
            {
              "goto": "s9",
              "id": "unwrapped-immediate-use",
              "label": "Unwrapped, immediate use only"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "assistant",
          "title": "Wrapped vs. unwrapped/immediate-use handling"
        },
        {
          "detail": "Arrange packages in the sterilizer per the unit's loading instructions so steam or the sterilant can circulate freely — packages not stacked flat against each other, pouches on edge, and the manufacturer's maximum load respected.",
          "id": "s9",
          "kind": "step",
          "materials": [
            "sterilizer racks or trays"
          ],
          "role": "assistant",
          "title": "Load the sterilizer"
        },
        {
          "detail": "Start the sterilizer on the cycle appropriate to the load (standard wrapped-instrument cycle) and let it run to completion without opening the door early. Record the cycle's start time, temperature, and pressure on the log for that load. The countdown shown here is a convenience placeholder only — the sterilizer's own cycle and the manufacturer's instructions govern the actual time and parameters; never substitute this timer for the unit's completed cycle.",
          "id": "s10",
          "kind": "timer",
          "materials": [
            "sterilizer log"
          ],
          "role": "assistant",
          "timer_seconds": 1800,
          "title": "Run the sterilizer cycle"
        },
        {
          "detail": "Allow the drying phase to complete inside the sterilizer before opening the door. Wet packages are treated as contaminated — moisture can wick bacteria through the wrap — and are not released to storage.",
          "id": "s11",
          "kind": "step",
          "role": "assistant",
          "title": "Dry the load"
        },
        {
          "detail": "Leave packages in or near the sterilizer to reach room temperature before moving them to storage. Do not stack or handle hot packages, and do not place hot packages directly onto a cold counter, which can cause condensation.",
          "id": "s12",
          "kind": "step",
          "role": "assistant",
          "title": "Cool the load before handling"
        },
        {
          "detail": "Before releasing any package to storage, confirm every internal and external chemical indicator on that load changed correctly. A load with a failed or ambiguous indicator does not go to storage and does not go to a patient — pull the load, do not use those instruments, and start the recheck process (re-sterilize once the cause is identified, or escalate to the office manager if the cause is unclear).",
          "gate": {
            "ack": "I have checked every internal and external chemical indicator on this load and confirm they all read correctly, or I have pulled this load and it is not going to storage or to a patient.",
            "type": "safety"
          },
          "id": "s13",
          "kind": "gate",
          "role": "assistant",
          "title": "Load-release decision"
        },
        {
          "detail": "Store released packages in a clean, dry, enclosed area away from sinks, vents, and traffic that could tear or wet the wrap. Rotate stock so older packages are used first, and inspect package integrity again at the point of use.",
          "id": "s14",
          "kind": "step",
          "materials": [
            "closed sterile-storage cabinet"
          ],
          "role": "office-manager",
          "title": "Move to sterility-maintenance storage"
        },
        {
          "detail": "Record the sterilizer's mechanical readouts (time, temperature, pressure) and the chemical indicator results for this load in the sterilization log, with the date and the initials of the person who ran the cycle.",
          "id": "s15",
          "kind": "step",
          "materials": [
            "sterilization log"
          ],
          "role": "office-manager",
          "title": "Log mechanical and chemical monitoring for the load"
        },
        {
          "detail": "At least weekly, run a biological indicator (spore test) through the sterilizer along with a routine load, following the test manufacturer's instructions, and send or incubate it per the test system used.",
          "id": "s16",
          "kind": "step",
          "materials": [
            "biological indicator (spore test) vials",
            "control vial",
            "incubator, if used in-office"
          ],
          "role": "office-manager",
          "title": "Run the weekly biological (spore) test"
        },
        {
          "detail": "When the spore test result comes back, record it in the sterilization log. A positive (failed) spore test means the sterilizer is suspect: stop using it, pull all loads processed since the last negative test, and escalate to the office manager or dentist before the sterilizer is returned to service.",
          "gate": {
            "ack": "I have reviewed this week's spore test result and, if it failed, have pulled the sterilizer from service and escalated rather than continuing to use it.",
            "type": "safety"
          },
          "id": "s17",
          "kind": "gate",
          "role": "office-manager",
          "title": "Review the spore test result"
        },
        {
          "detail": "File or retain the completed sterilization log entry (mechanical, chemical, and biological monitoring) per the practice's record-retention schedule so any load can be traced back if a question comes up later.",
          "id": "s18",
          "kind": "step",
          "materials": [
            "sterilization log archive"
          ],
          "role": "office-manager",
          "title": "File the load record"
        }
      ],
      "summary": "The full path a contaminated instrument takes from chairside to sterile storage: transport, holding, cleaning, inspection, packaging, sterilization, drying, cooling, storage, and the monitoring/record-keeping leg that proves the cycle worked.",
      "title": "Instrument Reprocessing Cycle",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California teledentistry statute B&P §1683.1",
          "source": "California teledentistry statute B&P §1683.1",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1683.1"
        },
        {
          "kind": "open_standard",
          "label": "ADA Policy on Teledentistry (open) — linked to the ADA current-policies index, the best available stable public entry point for this policy",
          "source": "ADA Policy on Teledentistry (open) — linked to the ADA current-policies index, the best available stable public entry point for this policy",
          "url": "https://www.ada.org/about/governance/current-policies"
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "tele-001",
      "kind": "clinical",
      "materials": [
        "telehealth consent form",
        "modality disclosure script",
        "patient portal or scheduling system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Front desk screens the reason for the visit against the practice's telehealth-eligible list (consults, follow-ups, triage, some post-op checks). Active bleeding, swelling, or trauma is redirected to an in-person or emergency path, not booked as telehealth.\n\nWhy: Not every complaint can be safely assessed on video; screening at booking avoids a wasted visit and a late redirect to emergency care.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the visit is appropriate for telehealth",
          "why": "Not every complaint can be safely assessed on video; screening at booking avoids a wasted visit and a late redirect to emergency care."
        },
        {
          "detail": "Send the patient a plain-language notice naming the modality (live video or store-and-forward photo/image review), what the visit can and cannot accomplish remotely, and that an in-person exam remains available on request at any time.\n\nWhy: Patients need to know a screen exam has limits and that choosing telehealth does not waive their right to be seen in person.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Send the modality disclosure before the appointment",
          "why": "Patients need to know a screen exam has limits and that choosing telehealth does not waive their right to be seen in person."
        },
        {
          "detail": "The signed or electronically acknowledged teledentistry consent form (modality, limitations, right to in-person alternative, recording policy if any) must be on file before the dentist starts the visit.\n\nWhy: Consent-before-treatment is the non-negotiable boundary; a verbal 'yes' on camera is not a substitute for the documented form.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Consent captured before the visit begins.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Consent captured before the visit begins",
          "why": "Consent-before-treatment is the non-negotiable boundary; a verbal 'yes' on camera is not a substitute for the documented form."
        },
        {
          "detail": "Dentist checks the record for the signed consent immediately before starting.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "yes",
              "label": "Consent on file, proceed"
            },
            {
              "goto": "s2",
              "id": "no",
              "label": "Not on file, pause the visit"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "dentist",
          "title": "Consent on file?"
        },
        {
          "detail": "Dentist briefly restates on camera what today's visit can and cannot determine remotely, and reminds the patient they can request an in-person exam instead at any point.\n\nWhy: A verbal restatement close to the exam catches any question the written form did not answer.",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Restate the modality and limits verbally at the start of the visit",
          "why": "A verbal restatement close to the exam catches any question the written form did not answer."
        },
        {
          "detail": "File the consent form reference, modality used, and a note that the in-person alternative was disclosed into the patient's chart.\n\nRecord: Consent form reference, modality used, and a note that the in-person alternative was disclosed, filed to the patient's chart.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Document consent and disclosure in the chart"
        },
        {
          "detail": "Visit proceeds under documented consent",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Visit proceeds under documented consent"
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Teledentistry consent, modality disclosure and right to in-person care — A patient books a video or store-and-forward consultation.",
      "title": "Teledentistry consent, modality disclosure and right to in-person care",
      "trigger": "A patient books a video or store-and-forward consultation",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California telehealth statute B&P §2290.5 (licensure and standard-of-care provisions)",
          "source": "California telehealth statute B&P §2290.5 (licensure and standard-of-care provisions)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=2290.5"
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "tele-002",
      "kind": "clinical",
      "materials": [
        "intake location field",
        "state licensure roster for the practice's providers",
        "compact/reciprocity reference if applicable"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "At the start of the call (or on the pre-visit intake form for store-and-forward), the patient states the city and state they are physically in right now — not their home address on file.\n\nWhy: Dental licensure is jurisdiction-based on where the patient physically is during the encounter, not where the practice or the patient's permanent address is.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Ask the patient to state their current physical location",
          "why": "Dental licensure is jurisdiction-based on where the patient physically is during the encounter, not where the practice or the patient's permanent address is."
        },
        {
          "detail": "Cross-check the stated state against the practice's current provider licensure roster.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "yes",
              "label": "Provider is licensed there, proceed"
            },
            {
              "goto": "s7",
              "id": "no",
              "label": "Not licensed there, cannot proceed as telehealth in that state"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the treating dentist licensed in that state?"
        },
        {
          "detail": "Compliance officer reviews the logged location and licensure match and signs off BEFORE the dentist proceeds with the encounter as telehealth — this gate blocks the visit itself, not just its later billing.\n\nWhy: Practicing across a state line without a matching license is a licensure violation with real consequences for the provider, so the check gets an explicit sign-off rather than resting on the dentist's own judgment alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer confirms the licensure match before the visit proceeds.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer confirms the licensure match before the visit proceeds",
          "why": "Practicing across a state line without a matching license is a licensure violation with real consequences for the provider, so the check gets an explicit sign-off rather than resting on the dentist's own judgment alone."
        },
        {
          "detail": "Dentist proceeds understanding the same standard of care and scope-of-practice rules apply on a telehealth visit as an in-person one in that jurisdiction.\n\nWhy: Telehealth changes the delivery channel, not the clinical standard the provider is held to.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Confirm standard of care applies as if in-person",
          "why": "Telehealth changes the delivery channel, not the clinical standard the provider is held to."
        },
        {
          "detail": "Log the patient-stated location, the confirming state match, and the licensure check outcome to the visit record.\n\nRecord: Patient-stated location, confirming state, and licensure check outcome logged to the visit record.",
          "id": "s5",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the location and licensure check"
        },
        {
          "detail": "Location and licensure resolved for this encounter",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Location and licensure resolved for this encounter"
        },
        {
          "detail": "Front desk offers rescheduling once the patient is back in a licensed state, an in-person visit, or a referral to a provider licensed where the patient currently is.\n\nWhy: The visit cannot lawfully proceed as telehealth in an unlicensed state, but the patient still needs a path to care.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer alternatives when the state does not match",
          "why": "The visit cannot lawfully proceed as telehealth in an unlicensed state, but the patient still needs a path to care."
        },
        {
          "detail": "Log the reason the visit was not conducted and which alternative was offered to the patient.\n\nRecord: Reason the visit was not conducted and which alternative was offered, logged for the practice's compliance record.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Document the declined visit and alternative offered"
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Verifying patient physical location and provider licensure in that state before the visit — A patient joins the call from out of state or while traveling.",
      "title": "Verifying patient physical location and provider licensure in that state before the visit",
      "trigger": "A patient joins the call from out of state or while traveling",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "regulation",
          "label": "HIPAA Security Rule 45 CFR 164 Subpart C (platform safeguards)",
          "source": "HIPAA Security Rule 45 CFR 164 Subpart C (platform safeguards)",
          "url": "https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-C"
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 120,
      "frequency": "as-needed",
      "id": "tele-003",
      "kind": "clinical",
      "materials": [
        "candidate platform vendor list",
        "business associate agreement template",
        "identity-verification procedure"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "it-vendor",
        "compliance-officer",
        "practice-owner"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "IT vendor or compliance officer requests a business associate agreement from the video platform before any patient data flows through it.\n\nWhy: A platform carrying PHI without a signed BAA is a HIPAA gap regardless of how secure the software otherwise is.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the platform will sign a business associate agreement",
          "why": "A platform carrying PHI without a signed BAA is a HIPAA gap regardless of how secure the software otherwise is."
        },
        {
          "detail": "Confirm: encryption in transit (TLS) and, where available, end-to-end encryption for the video/audio stream; access controls and unique logins for staff accounts; automatic session timeout; audit logging of who joined which visit and when.\n\nWhy: These map to the HIPAA Security Rule's technical safeguard requirements — access control, audit controls, transmission security.",
          "id": "s2",
          "kind": "step",
          "role": "it-vendor",
          "title": "Verify technical safeguards",
          "why": "These map to the HIPAA Security Rule's technical safeguard requirements — access control, audit controls, transmission security."
        },
        {
          "detail": "Choose a consistent identity-check method for telehealth check-in (e.g., confirming name plus date of birth verbally, or a portal login tied to the patient's existing chart) and train front desk to apply it every time.\n\nWhy: A remote visit removes the in-person ID glance at check-in, so the practice needs a deliberate substitute to avoid seeing the wrong patient's information.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Set up patient identity verification for check-in",
          "why": "A remote visit removes the in-person ID glance at check-in, so the practice needs a deliberate substitute to avoid seeing the wrong patient's information."
        },
        {
          "detail": "Compliance officer confirms the BAA is signed, safeguards checklist is complete, and identity verification is trained before the platform is used with any patient.\n\nWhy: A named sign-off before go-live prevents a convenient platform choice from skipping the compliance review under time pressure.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer sign-off before go-live.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer sign-off before go-live",
          "why": "A named sign-off before go-live prevents a convenient platform choice from skipping the compliance review under time pressure."
        },
        {
          "detail": "File the signed BAA, completed safeguards checklist, and sign-off date into the compliance program's vendor record.\n\nRecord: Signed BAA, safeguards checklist, and sign-off date filed in the compliance program's vendor record.",
          "id": "s5",
          "kind": "step",
          "role": "compliance-officer",
          "title": "File the platform's compliance record"
        },
        {
          "detail": "Schedule an annual re-check of the BAA status, safeguards, and any platform changes since the last review.\n\nWhy: Vendors change features and security posture; an annual recheck catches drift before it becomes a gap.\n\nCadence: 0 minute(s) (no valid timer duration in source — downgraded from a timer step).",
          "id": "s6",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Recur annually for platform security review",
          "why": "Vendors change features and security posture; an annual recheck catches drift before it becomes a gap."
        },
        {
          "detail": "Platform approved for telehealth use",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Platform approved for telehealth use"
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Telehealth platform selection — BAA, encryption and identity verification — The practice adopts or changes its video platform.",
      "title": "Telehealth platform selection — BAA, encryption and identity verification",
      "trigger": "The practice adopts or changes its video platform",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "California teledentistry statute B&P §1683.1 (store-and-forward provisions)",
          "source": "California teledentistry statute B&P §1683.1 (store-and-forward provisions)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1683.1"
        },
        {
          "kind": "open_standard",
          "label": "ADA Policy on Teledentistry (open) — linked to the ADA current-policies index, the best available stable public entry point for this policy",
          "source": "ADA Policy on Teledentistry (open) — linked to the ADA current-policies index, the best available stable public entry point for this policy",
          "url": "https://www.ada.org/about/governance/current-policies"
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 20,
      "frequency": "per-use",
      "id": "tele-004",
      "kind": "clinical",
      "materials": [
        "secure upload portal",
        "image quality checklist",
        "asynchronous review note template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Images and any accompanying description of symptoms are uploaded through the practice's secure patient portal, never emailed or texted as attachments.\n\nWhy: Unencrypted email or text is not an approved PHI transmission path; the portal is the controlled channel.",
          "id": "s1",
          "kind": "step",
          "role": "patient",
          "title": "Patient or hygienist uploads images through the secure portal",
          "why": "Unencrypted email or text is not an approved PHI transmission path; the portal is the controlled channel."
        },
        {
          "detail": "Confirm: adequate lighting, image in focus, the relevant area fully visible, and (for radiographs) diagnostic quality comparable to an in-office capture.\n\nWhy: A store-and-forward review is only as good as the image; a blurry or poorly lit photo can miss what an in-person exam would catch.",
          "id": "s2",
          "kind": "step",
          "role": "dentist",
          "title": "Check image quality before relying on it clinically",
          "why": "A store-and-forward review is only as good as the image; a blurry or poorly lit photo can miss what an in-person exam would catch."
        },
        {
          "detail": "Dentist judges whether the submitted images and description are sufficient to form an assessment.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "adequate",
              "label": "Adequate, proceed with review"
            },
            {
              "goto": "s9",
              "id": "inadequate",
              "label": "Not adequate, request new images or bring patient in"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "dentist",
          "title": "Is the image adequate for a clinical opinion?"
        },
        {
          "detail": "Dentist reviews the images against the reported symptoms and forms a preliminary assessment, explicitly noting what asynchronous review can and cannot rule out.\n\nWhy: Store-and-forward review has real limits (no depth perception, no percussion or palpation); the note should say what remains unconfirmed.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist reviews and forms a preliminary assessment",
          "why": "Store-and-forward review has real limits (no depth perception, no percussion or palpation); the note should say what remains unconfirmed."
        },
        {
          "detail": "Dentist decides whether the asynchronous review is sufficient to close the loop or whether the patient needs to be seen in person.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "closed",
              "label": "Sufficient, communicate the assessment and next steps"
            },
            {
              "goto": "s9",
              "id": "bring-in",
              "label": "Recommend an in-person visit"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the finding need an in-person visit?"
        },
        {
          "detail": "Dentist confirms the preliminary assessment and stated limits are accurate before the finding is sent to the patient as a clinical opinion.\n\nWhy: A remote finding reaching the patient as a stated clinical opinion carries the same weight as an in-person one, so it gets an explicit licensed sign-off rather than being sent automatically.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off on the asynchronous assessment before it is communicated to the patient.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off on the asynchronous assessment before it is communicated to the patient",
          "why": "A remote finding reaching the patient as a stated clinical opinion carries the same weight as an in-person one, so it gets an explicit licensed sign-off rather than being sent automatically."
        },
        {
          "detail": "File the images reviewed, the assessment, the stated limits of the asynchronous review, and the communicated next steps to the chart.\n\nRecord: Images reviewed, assessment, stated limits of the asynchronous review, and communicated next steps filed to the chart.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Document the asynchronous review outcome"
        },
        {
          "detail": "Asynchronous review closed or escalated",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Asynchronous review closed or escalated"
        },
        {
          "detail": "Front desk contacts the patient to either schedule an in-person visit or request higher-quality replacement images, with the reason explained in plain language.",
          "id": "s9",
          "kind": "step",
          "role": "front-desk",
          "title": "Route to front desk for in-person scheduling or re-upload request"
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Store-and-forward photo and radiograph review, limits and documentation — A patient uploads photos for triage, or a hygienist sends images to the supervising dentist.",
      "title": "Store-and-forward photo and radiograph review, limits and documentation",
      "trigger": "A patient uploads photos for triage, or a hygienist sends images to the supervising dentist",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "Ryan Haight Act, 21 U.S.C. §829(e) (controlled substances via telemedicine — requires an in-person exam or a DEA-registered telemedicine exception before prescribing a controlled substance remotely)",
          "source": "Ryan Haight Act, 21 U.S.C. §829(e) (controlled substances via telemedicine — requires an in-person exam or a DEA-registered telemedicine exception before prescribing a controlled substance remotely)",
          "url": "https://www.deadiversion.usdoj.gov/telemedicine.html"
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 10,
      "frequency": "per-use",
      "id": "tele-005",
      "kind": "clinical",
      "materials": [
        "e-prescribing system",
        "controlled-substance prescribing checklist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Dentist checks the medication category before writing anything — non-controlled items like most antibiotics and many analgesics are generally prescribable via telehealth; controlled substances are restricted.\n\nWhy: The two categories have different legal rules and the mistake of treating them the same is the highest-severity risk in this protocol.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Determine whether the needed medication is a controlled substance",
          "why": "The two categories have different legal rules and the mistake of treating them the same is the highest-severity risk in this protocol."
        },
        {
          "detail": "Dentist classifies the requested or clinically indicated medication.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no",
              "label": "Not controlled, proceed with telehealth prescribing"
            },
            {
              "goto": "s6",
              "id": "yes",
              "label": "Controlled substance requested"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "dentist",
          "title": "Is it a controlled substance?"
        },
        {
          "detail": "Dentist sends the prescription through the e-prescribing system and documents the diagnosis and rationale supporting it, same as an in-person visit.\n\nWhy: Documentation standards do not relax because the visit was remote.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "E-prescribe and document the clinical rationale",
          "why": "Documentation standards do not relax because the visit was remote."
        },
        {
          "detail": "File the medication, dose, diagnosis, and prescribing rationale to the patient's chart. For a controlled substance, also record which qualifying condition applied — a documented prior in-person exam (with date) or the specific DEA-registered telemedicine exception relied on — so the legal basis for the prescription is itself part of the record.\n\nRecord: Medication, dose, diagnosis, and rationale filed to the chart; for controlled substances, the qualifying condition (prior in-person exam date or named DEA telemedicine exception) is also recorded.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Document the prescription"
        },
        {
          "detail": "Prescribing decision resolved and documented",
          "id": "s5",
          "kind": "step",
          "role": "dentist",
          "title": "Prescribing decision resolved and documented"
        },
        {
          "detail": "A controlled substance generally requires either a prior in-person medical evaluation or that the prescriber and encounter qualify under a DEA-registered telemedicine exception; the dentist must confirm which applies before proceeding.\n\nWhy: The Ryan Haight Act restricts remote controlled-substance prescribing specifically to close a known abuse pathway; this is the single highest-risk decision point in the protocol.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off required before any controlled-substance prescribing decision.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off required before any controlled-substance prescribing decision",
          "why": "The Ryan Haight Act restricts remote controlled-substance prescribing specifically to close a known abuse pathway; this is the single highest-risk decision point in the protocol."
        },
        {
          "detail": "Dentist confirms whether the qualifying condition is actually met, not assumed.",
          "forks": [
            {
              "goto": "s3",
              "id": "qualifies",
              "label": "Qualifying condition confirmed, may prescribe"
            },
            {
              "advised": true,
              "goto": "s8",
              "id": "no-qualify",
              "label": "Does not qualify, patient must be seen in person first"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Does an exception or prior in-person exam apply?"
        },
        {
          "detail": "Front desk schedules an in-person exam before any controlled-substance prescription can be considered, and explains the reason to the patient.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Route to front desk to schedule an in-person visit"
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Prescribing via telehealth — antibiotics and analgesics allowed, controlled-substance restrictions — A telehealth patient needs a prescription.",
      "title": "Prescribing via telehealth — antibiotics and analgesics allowed, controlled-substance restrictions",
      "trigger": "A telehealth patient needs a prescription",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "911 nationwide emergency number",
          "source": "911 nationwide emergency number"
        },
        {
          "kind": "statute",
          "label": "California telehealth statute B&P §2290.5 (standard of care applies as in-person)",
          "source": "California telehealth statute B&P §2290.5 (standard of care applies as in-person)",
          "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=2290.5"
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 5,
      "frequency": "as-needed",
      "id": "tele-006",
      "kind": "clinical",
      "materials": [
        "patient's stated address on file for this visit",
        "local emergency number reference",
        "incident log template"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "front-desk",
        "ems",
        "patient",
        "caregiver"
      ],
      "schema": "protocol_v1",
      "severity": 5,
      "steps": [
        {
          "detail": "The instant the dentist sees airway swelling, uncontrolled bleeding, loss of consciousness, or any sign of a life-threatening emergency on camera, front desk or dentist calls 911 (or the local emergency number) right away. This happens before any further questioning or troubleshooting the video connection.\n\nWhy: A telehealth emergency is a real emergency at a real address; the video screen is not a barrier to calling for help, and delay is the single largest risk in this protocol.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Call 911 immediately — do not wait to finish the assessment.",
            "type": "safety"
          },
          "id": "s1",
          "kind": "gate",
          "role": "front-desk",
          "title": "Call 911 immediately — do not wait to finish the assessment",
          "why": "A telehealth emergency is a real emergency at a real address; the video screen is not a barrier to calling for help, and delay is the single largest risk in this protocol."
        },
        {
          "detail": "Confirm the patient's physical address right now (not the address on file, if they are traveling) and relay it to the 911 dispatcher immediately; if a caregiver is present or reachable, get them on the line too.\n\nWhy: EMS cannot respond to a video call — they need a physical address, and a remote visit has no automatic location signal the way an in-person office does.",
          "id": "s2",
          "kind": "step",
          "role": "front-desk",
          "title": "Get the patient's exact current address to the 911 dispatcher",
          "why": "EMS cannot respond to a video call — they need a physical address, and a remote visit has no automatic location signal the way an in-person office does."
        },
        {
          "detail": "Dentist stays on camera and gives instructions matched to the presenting emergency, remaining aware of the limits of what can be done remotely: uncontrolled bleeding — instruct firm direct pressure on the site with clean gauze or cloth; airway swelling — ask whether the patient has their own epinephrine auto-injector and instruct the caregiver to use it immediately per its label (this is the licensed-first-aid-standard first-line action, ahead of anything else besides the 911 call already placed); collapse or loss of consciousness — instruct the caregiver to lay the patient supine with legs raised (not seated) and check that the airway is clear.\n\nWhy: The three named trigger presentations (airway swelling, uncontrolled bleeding, collapse) have materially different correct first-aid actions; a single generic instruction is wrong for at least two of the three. Attributed to general first-aid standard of care, subject to licensed review.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Give symptom-specific first-aid instructions while EMS is en route",
          "why": "The three named trigger presentations (airway swelling, uncontrolled bleeding, collapse) have materially different correct first-aid actions; a single generic instruction is wrong for at least two of the three. Attributed to general first-aid standard of care, subject to licensed review."
        },
        {
          "detail": "When EMS arrives or contacts the practice, front desk or dentist relays what was observed on the call, when symptoms began, and any relevant medical history on file.",
          "id": "s4",
          "kind": "step",
          "role": "front-desk",
          "title": "Hand off to EMS on arrival"
        },
        {
          "detail": "Compliance officer reviews the emergency timeline and EMS handoff details and signs off before the incident is filed as closed.\n\nWhy: A life-threatening incident gets a named licensed/compliance review before closure, not just a front-desk log entry, so the practice can show it was actually reviewed.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance officer sign-off on the incident record before it is closed.",
            "role": "compliance-officer",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "compliance-officer",
          "title": "Compliance officer sign-off on the incident record before it is closed",
          "why": "A life-threatening incident gets a named licensed/compliance review before closure, not just a front-desk log entry, so the practice can show it was actually reviewed."
        },
        {
          "detail": "Dentist or front desk follows up within 24 hours to check on the outcome and update the chart.\n\nWhy: Closing the loop confirms the patient reached care and gives the practice the actual outcome for its record.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Follow up with the patient or caregiver after the emergency",
          "why": "Closing the loop confirms the patient reached care and gives the practice the actual outcome for its record."
        },
        {
          "detail": "Log the timeline of symptom onset, the 911 call time, the address given, EMS handoff details, and the follow-up outcome.\n\nRecord: Timeline of symptom onset, 911 call time, address given, EMS handoff details, and follow-up outcome logged to the compliance incident log and the patient's chart.",
          "id": "s7",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Log the emergency incident"
        },
        {
          "detail": "Emergency escalation complete and logged",
          "id": "s8",
          "kind": "step",
          "role": "dentist",
          "title": "Emergency escalation complete and logged"
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Emergency during a telehealth visit — location capture, 911 dispatch and follow-up — A patient on video shows airway swelling, uncontrolled bleeding or collapses.",
      "title": "Emergency during a telehealth visit — location capture, 911 dispatch and follow-up",
      "trigger": "A patient on video shows airway swelling, uncontrolled bleeding or collapses",
      "trigger_kind": "emergency",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "open_standard",
          "label": "ADA Policy on Teledentistry (open) — linked to the ADA current-policies index, the best available stable public entry point for this policy",
          "source": "ADA Policy on Teledentistry (open) — linked to the ADA current-policies index, the best available stable public entry point for this policy",
          "url": "https://www.ada.org/about/governance/current-policies"
        },
        {
          "kind": "regulation",
          "label": "HIPAA documentation retention 45 CFR 164.316",
          "source": "HIPAA documentation retention 45 CFR 164.316",
          "url": "https://www.ecfr.gov/current/title-45/section-164.316"
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "tele-007",
      "kind": "clinical",
      "materials": [
        "visit note template",
        "CDT modality/place-of-service code reference",
        "payer telehealth coverage policy reference"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "billing",
        "insurance-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Dentist documents the modality used, findings, assessment, and plan in the visit note before the end of the day, same as an in-person encounter.\n\nWhy: Delay increases the chance of missed or inaccurate detail, and payers often expect prompt documentation for telehealth claims.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist completes the visit note same day",
          "why": "Delay increases the chance of missed or inaccurate detail, and payers often expect prompt documentation for telehealth claims."
        },
        {
          "detail": "Billing selects the CDT and place-of-service codes that correctly reflect the telehealth modality used (synchronous video vs asynchronous store-and-forward), per the payer's current telehealth policy.\n\nWhy: Coding a telehealth visit as if it were in-person is the most common cause of claim denial for these encounters.",
          "id": "s2",
          "kind": "step",
          "role": "billing",
          "title": "Apply the correct modality and place-of-service coding",
          "why": "Coding a telehealth visit as if it were in-person is the most common cause of claim denial for these encounters."
        },
        {
          "detail": "Insurance coordinator checks the specific payer's telehealth coverage policy before submitting.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "covered",
              "label": "Covered, submit the claim"
            },
            {
              "goto": "s7",
              "id": "not-covered",
              "label": "Not covered or unclear, verify with payer first"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does the payer cover this modality for this service?"
        },
        {
          "detail": "Dentist or office manager reviews the coded claim (modality, place-of-service, CDT codes, visit note reference) and signs off before billing submits it to the payer — a claim never auto-submits.\n\nWhy: Claims never auto-submit: a coded claim reaching the payer is a billing decision made on the practice's behalf, so it gets an explicit licensed/managerial sign-off before it leaves the building, the same boundary the daily-claim-batch-review protocol applies to every other claim.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Licensed sign-off before the claim is submitted.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "dentist",
          "title": "Licensed sign-off before the claim is submitted",
          "why": "Claims never auto-submit: a coded claim reaching the payer is a billing decision made on the practice's behalf, so it gets an explicit licensed/managerial sign-off before it leaves the building, the same boundary the daily-claim-batch-review protocol applies to every other claim."
        },
        {
          "detail": "Submit the claim with the correct modality and place-of-service codes and attach the visit note reference.\n\nRecord: Claim submitted with modality and place-of-service codes, visit note reference attached.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Submit the claim"
        },
        {
          "detail": "Visit documented and claim submitted",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Visit documented and claim submitted"
        },
        {
          "detail": "Insurance coordinator contacts the payer or checks the published policy to confirm coverage or the patient's financial responsibility before the claim goes out.\n\nWhy: Submitting a claim likely to be denied wastes staff time and delays the patient's accurate cost information.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Verify coverage with the payer before submitting",
          "why": "Submitting a claim likely to be denied wastes staff time and delays the patient's accurate cost information."
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Telehealth visit documentation, modality codes and payer rules — A teledentistry encounter ends and needs a note and claim.",
      "title": "Telehealth visit documentation, modality codes and payer rules",
      "trigger": "A teledentistry encounter ends and needs a note and claim",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "B&P §1683.1 is a provider-identification-disclosure requirement only and does not address supervision levels; B&P §2290.5 (telehealth definition, public-health-setting use) was searched but no quotable passage confirming hygienist supervision-level rules was found. general supervision per the specific procedure and setting before any off-site/teledentistry hygiene visit) — Practice policy — no published authority governs this step.",
          "practice_policy": {
            "ruling": "F-2026-09-05-R",
            "was": "B&P §1683.1 is a provider-identification-disclosure requirement only and does not address supervision levels; B&P §2290.5 (telehealth definition, public-health-setting use) was searched but no quotable passage confirming hygienist supervision-level rules was found — generic functional equivalent (confirm direct vs. general supervision per the specific procedure and setting before any off-site/teledentistry hygiene visit)"
          },
          "repaired": {
            "action": "generic",
            "evidence": "§1683.1 full text (2 subsections): requires disclosure of the treating dentist's name/license/contact and states a violation is unprofessional conduct — nothing about supervision levels. Search on §2290.5 surfaced only that it defines 'telehealth' and permits its use for hygienist-to-dentist communication in public-health settings (schools, Head Start, community clinics); a fetch of the statute's full text to confirm supervision-level content directly was blocked by network egress, so I could not read text that actually supports naming §2290.5 as the authority.",
            "ticket": "PROT-017",
            "was": {
              "source": "California teledentistry statute B&P §1683.1 (supervision level provisions for remote review of hygiene services)",
              "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=1683.1"
            }
          },
          "source": "B&P §1683.1 is a provider-identification-disclosure requirement only and does not address supervision levels; B&P §2290.5 (telehealth definition, public-health-setting use) was searched but no quotable passage confirming hygienist supervision-level rules was found. general supervision per the specific procedure and setting before any off-site/teledentistry hygiene visit) — Practice policy — no published authority governs this step."
        }
      ],
      "class": "teledentistry",
      "department": "compliance",
      "duration_min": 30,
      "frequency": "per-shift",
      "id": "tele-008",
      "kind": "clinical",
      "materials": [
        "supervision-level reference for the practicing state",
        "off-site equipment checklist",
        "remote review connection to the supervising dentist"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "hygienist",
        "assistant",
        "compliance-officer"
      ],
      "schema": "protocol_v1",
      "severity": 4,
      "steps": [
        {
          "detail": "Compliance officer confirms which supervision level (general, remote, or another named level under state law) applies to the specific off-site setting and procedures planned, before the hygienist leaves the office.\n\nWhy: Supervision requirements vary by state and by setting; confirming in advance avoids performing a procedure outside the authorized scope for that level.",
          "id": "s1",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Confirm the applicable supervision level before the off-site session",
          "why": "Supervision requirements vary by state and by setting; confirming in advance avoids performing a procedure outside the authorized scope for that level."
        },
        {
          "detail": "Confirm: portable equipment for the planned procedures, a secure device to transmit images or notes to the supervising dentist, and that the remote-review connection has been tested before departure.\n\nWhy: A failed connection discovered on-site wastes the visit and delays care for every patient scheduled that session.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Pack and verify off-site equipment and remote-review connection",
          "why": "A failed connection discovered on-site wastes the visit and delays care for every patient scheduled that session."
        },
        {
          "detail": "Front desk or compliance officer confirms signed parent/guardian consent for teledentistry-supervised care is on file for each minor patient before the hygienist begins any procedure at the off-site location.\n\nWhy: Off-site school- or facility-based hygiene care for minors requires documented guardian consent per visit or program enrollment, the same consent boundary the practice applies to any other teledentistry encounter.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Guardian consent on file before care begins.",
            "type": "safety"
          },
          "id": "s3",
          "kind": "gate",
          "role": "front-desk",
          "title": "Guardian consent on file before care begins",
          "why": "Off-site school- or facility-based hygiene care for minors requires documented guardian consent per visit or program enrollment, the same consent boundary the practice applies to any other teledentistry encounter."
        },
        {
          "detail": "Hygienist performs only the procedures authorized under the confirmed supervision level and documents findings for each patient as the session proceeds.\n\nWhy: Staying within the confirmed scope is what makes the off-site model lawful under the applicable supervision level.",
          "id": "s4",
          "kind": "step",
          "role": "hygienist",
          "title": "Hygienist performs care within authorized scope",
          "why": "Staying within the confirmed scope is what makes the off-site model lawful under the applicable supervision level."
        },
        {
          "detail": "Hygienist sends notes and any images through the secure connection to the supervising dentist, who reviews and either approves the treatment plan or flags a case for follow-up.",
          "id": "s5",
          "kind": "step",
          "role": "hygienist",
          "title": "Transmit findings to the supervising dentist for remote review"
        },
        {
          "detail": "Supervising dentist reviews and signs off on each patient's findings and any recommended treatment plan before it is finalized, consistent with the confirmed supervision level.\n\nWhy: Remote supervision does not remove the requirement for licensed clinical sign-off on the treatment decisions made under it.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off on each case before it is finalized.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off on each case before it is finalized",
          "why": "Remote supervision does not remove the requirement for licensed clinical sign-off on the treatment decisions made under it."
        },
        {
          "detail": "Dentist decides whether the remote review is sufficient or the patient should be scheduled for an in-person visit at the practice.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "sufficient",
              "label": "Sufficient, close the case at this session"
            },
            {
              "goto": "s10",
              "id": "followup",
              "label": "Needs in-person follow-up"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the case need an in-person follow-up?"
        },
        {
          "detail": "File the supervision level applied, procedures performed, and dentist sign-off to each patient's record.\n\nRecord: Supervision level applied, procedures performed, and dentist sign-off filed to each patient's record.",
          "id": "s8",
          "kind": "step",
          "role": "hygienist",
          "title": "Document the closed off-site case"
        },
        {
          "detail": "Off-site session closed with supervision documented",
          "id": "s9",
          "kind": "step",
          "role": "compliance-officer",
          "title": "Off-site session closed with supervision documented"
        },
        {
          "detail": "Front desk schedules the patient for an in-person visit at the practice and notes the reason from the dentist's review.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Route to front desk to schedule the in-person follow-up"
        }
      ],
      "subclass": "telehealth-and-teledentistry",
      "summary": "Hygienist or assistant off-site care under teledentistry supervision (scope and supervision level) — A hygienist provides care at a school or facility with the dentist reviewing remotely.",
      "title": "Hygienist or assistant off-site care under teledentistry supervision (scope and supervision level)",
      "trigger": "A hygienist provides care at a school or facility with the dentist reviewing remotely",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "tpf-001",
      "kind": "operational",
      "materials": [
        "chart/treatment plan module",
        "radiographs and intraoral photos",
        "printed or digital plan summary"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator",
        "assistant"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Dentist finalizes the diagnosis, sequences procedures in clinical priority order, and enters CDT codes into the chart's treatment plan module.\n\nWhy: A plan cannot be presented until it is complete and clinically sequenced — presenting an unfinished plan invites confusion and rework.",
          "id": "s1",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist completes and sequences the diagnosis and plan",
          "why": "A plan cannot be presented until it is complete and clinically sequenced — presenting an unfinished plan invites confusion and rework."
        },
        {
          "detail": "Pull radiographs, intraoral photos, and a printed or on-screen plan summary the coordinator will use in the consult room.",
          "id": "s2",
          "kind": "step",
          "role": "assistant",
          "title": "Assistant assembles presentation materials"
        },
        {
          "detail": "Dentist confirms the plan in the chart is final and signs/locks it before any financial figure is quoted to the patient.\n\nWhy: Case presentation and cost figures must trace back to a plan the licensed provider actually finalized, not a working draft — this is the licensed-review gate non-negotiable #4 requires.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist signs off on the plan before handoff.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist signs off on the plan before handoff",
          "why": "Case presentation and cost figures must trace back to a plan the licensed provider actually finalized, not a working draft — this is the licensed-review gate non-negotiable #4 requires."
        },
        {
          "detail": "Confirm: plan is signed, CDT codes present, procedures sequenced, urgency/timely-window flag set, imaging attached.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Coordinator verifies the chart is presentation-ready"
        },
        {
          "detail": "Decide whether to present now (patient still in office, plan is straightforward) or schedule a dedicated consultation visit (large or multi-specialty case).",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "same-day",
              "label": "Present same-day, patient still in office"
            },
            {
              "goto": "s9",
              "id": "separate-consult",
              "label": "Route to a dedicated large-case consultation visit"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "Route to same-day or a dedicated consult visit"
        },
        {
          "detail": "Dentist briefs the coordinator verbally on diagnosis, urgency and any patient concerns, then the coordinator proceeds directly to chairside presentation.",
          "id": "s6",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist hands the patient to the coordinator now"
        },
        {
          "detail": "Record handoff timestamp, plan version, and routing decision (same-day vs dedicated consult) in the PMS chart notes.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the handoff"
        },
        {
          "detail": "Handoff complete",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Handoff complete"
        },
        {
          "detail": "Coordinator asks front desk to book a separate consultation appointment and prepares the case for that visit per the large-case protocol.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Front desk schedules a dedicated consult visit"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Doctor-to-coordinator treatment plan handoff — Diagnosis is complete and the plan is entered, sequenced and signed by the dentist before anyone presents it.",
      "title": "Doctor-to-coordinator treatment plan handoff",
      "trigger": "Diagnosis is complete and the plan is entered, sequenced and signed by the dentist before anyone presents it",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "tpf-002",
      "kind": "operational",
      "materials": [
        "consult room",
        "visual aids (photos/radiographs/models)",
        "financial estimate worksheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Lay out visual aids, the plan summary and a blank financial worksheet before bringing the patient in.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Set up the consult room"
        },
        {
          "detail": "Restate the dentist's findings in plain language using the visual aids; do not add new clinical interpretation.\n\nWhy: The coordinator presents the dentist's plan — adding independent clinical opinion oversteps scope and creates liability.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Walk the patient through the diagnosis in plain language",
          "why": "The coordinator presents the dentist's plan — adding independent clinical opinion oversteps scope and creates liability."
        },
        {
          "detail": "For each proposed procedure, cover: why it's needed, what it involves, when it should happen, what it costs, and what the alternatives are (including no treatment).",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Cover the core presentation points"
        },
        {
          "detail": "Judge whether the question is clinical (needs the dentist) or administrative/financial (coordinator can answer).",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "continue",
              "label": "Question is administrative/financial — continue"
            },
            {
              "goto": "s11",
              "id": "return-dentist",
              "label": "Question is clinical — bring the dentist back in"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "Does the patient ask something outside coordinator scope?"
        },
        {
          "detail": "Move to the financial estimate presentation (fee, estimated insurance benefit, patient portion, assumptions and expiry date).",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Transition to the cost conversation"
        },
        {
          "detail": "Ask directly whether the patient would like to move forward, and offer to schedule the first visit before they leave.",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Ask for a decision and offer to schedule"
        },
        {
          "detail": "Patient accepts and wants to schedule now, or wants more time.",
          "forks": [
            {
              "advised": true,
              "goto": "s8",
              "id": "accept",
              "label": "Accept and schedule now"
            },
            {
              "goto": "s12",
              "id": "not-ready",
              "label": "Not ready today"
            }
          ],
          "id": "s7",
          "kind": "fork",
          "role": "patient",
          "title": "Patient decides"
        },
        {
          "detail": "Coordinator hands the patient to the scheduler to book the first appointment in the plan sequence.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to scheduling"
        },
        {
          "detail": "Record outcome (accepted/deferred), procedures discussed, and quoted amount in the PMS.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the presentation outcome"
        },
        {
          "detail": "Presentation complete",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Presentation complete"
        },
        {
          "detail": "Dentist briefly returns to the room to answer the specific clinical question directly, then hands back to the coordinator.",
          "id": "s11",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist re-enters to answer the clinical question"
        },
        {
          "detail": "Add the patient to the practice's structured follow-up list (see patient-wants-to-think-about-it protocol) rather than letting the plan go untracked.",
          "id": "s12",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Enter the patient into the follow-up cadence list"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Same-day treatment presentation in the consult room — A signed plan is handed off while the patient is still in the office.",
      "title": "Same-day treatment presentation in the consult room",
      "trigger": "A signed plan is handed off while the patient is still in the office",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 45,
      "frequency": "per-patient",
      "id": "tpf-003",
      "kind": "operational",
      "materials": [
        "dedicated consult room/time block",
        "models or 3D imaging",
        "phased written plan document",
        "referral letters if multi-specialty"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "dentist",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Book a visit separate from the exam appointment, long enough to cover a complex or multi-specialty plan without rushing.\n\nWhy: Complex cases need unhurried time; folding them into a normal chair slot shortchanges the explanation and the schedule.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Schedule a dedicated consultation visit",
          "why": "Complex cases need unhurried time; folding them into a normal chair slot shortchanges the explanation and the schedule."
        },
        {
          "detail": "Assemble models or 3D imaging, a written phase-by-phase plan, and any specialist referral letters needed for the visit.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Prepare detailed presentation materials"
        },
        {
          "detail": "Dentist walks the patient through the diagnosis, the reasoning behind the phasing, and answers clinical questions directly.",
          "id": "s3",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist presents the clinical overview"
        },
        {
          "detail": "Dentist steps back and the coordinator takes over for scheduling and financial discussion.",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Dentist hands the room to the coordinator"
        },
        {
          "detail": "Confirm the patient understands: number of phases, timeline between phases, whether outside referrals are needed, and the estimated total cost.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Cover the phased-plan checklist"
        },
        {
          "detail": "Large cases warrant explicitly offering the option to take records for a second opinion rather than pressuring a same-visit decision.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "proceed",
              "label": "Proceed to financial estimate now"
            },
            {
              "goto": "s10",
              "id": "second-opinion",
              "label": "Wants time or a second opinion"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "patient",
          "title": "Does the patient want time or a second opinion?"
        },
        {
          "detail": "Continue into the financial estimate and insurance-portion presentation protocol.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Proceed to the financial estimate presentation"
        },
        {
          "detail": "Record phases discussed, materials provided, second-opinion request (if any), and next step in the PMS.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the consult outcome"
        },
        {
          "detail": "Large-case consultation complete",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Large-case consultation complete"
        },
        {
          "detail": "Provide copies of relevant images/records if requested, and log the request; route the patient into the follow-up cadence.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Offer copies of records on request"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Large or multi-phase case consultation visit — A plan exceeds the practice's consult threshold or involves several specialties.",
      "title": "Large or multi-phase case consultation visit",
      "trigger": "A plan exceeds the practice's consult threshold or involves several specialties",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "tpf-004",
      "kind": "operational",
      "materials": [
        "written estimate template",
        "insurance benefit breakdown",
        "fee schedule"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "insurance-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm eligibility, remaining benefit, deductible status and coverage percentages for the planned procedures.",
          "id": "s1",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Pull the patient's insurance benefit details"
        },
        {
          "detail": "Enter the full fee, estimated insurance portion, and estimated patient portion into the written estimate template, procedure by procedure.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Build the written estimate"
        },
        {
          "detail": "Note that the insurance figure is an estimate, not a guarantee of payment, list the assumptions it relies on (e.g. plan year, remaining benefit), and set an expiry date for the quoted fees.\n\nWhy: Insurance estimates can be wrong for reasons outside the practice's control — writing the assumptions down protects both the patient and the practice from a surprise later.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "State assumptions and expiry in writing",
          "why": "Insurance estimates can be wrong for reasons outside the practice's control — writing the assumptions down protects both the patient and the practice from a surprise later."
        },
        {
          "detail": "Read through the fee, estimated benefit, patient portion, assumptions and expiry date with the patient before asking for a decision.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the figures to the patient"
        },
        {
          "detail": "Patient is ready to proceed, or needs to check on payment options first.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "proceed",
              "label": "Ready to proceed to scheduling"
            },
            {
              "goto": "s9",
              "id": "payment-options",
              "label": "Needs payment options first"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "patient",
          "title": "Patient responds to the estimate"
        },
        {
          "detail": "Coordinator hands the patient to scheduling with the accepted estimate attached.",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand off to scheduling"
        },
        {
          "detail": "Save a copy of the signed/dated written estimate in the patient's file with its expiry date.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "File the written estimate"
        },
        {
          "detail": "Estimate presentation complete",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Estimate presentation complete"
        },
        {
          "detail": "Coordinator routes the patient into the payment-options-and-third-party-financing protocol.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Route to payment options discussion"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Financial estimate and insurance-portion presentation — Any presented plan — fee, estimated benefit, patient portion, assumptions and expiry stated in writing.",
      "title": "Financial estimate and insurance-portion presentation",
      "trigger": "Any presented plan — fee, estimated benefit, patient portion, assumptions and expiry stated in writing",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate requirements — itemized services, expected charges, and notice of the patient-provider dispute resolution process",
          "source": "No Surprises Act good faith estimate requirements — itemized services, expected charges, and notice of the patient-provider dispute resolution process",
          "url": "https://www.cms.gov/nosurprises"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "tpf-005",
      "kind": "operational",
      "materials": [
        "itemized CDT code/fee list",
        "good faith estimate template",
        "notice of patient dispute-resolution rights"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "front-desk",
        "billing",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Front desk flags the patient as uninsured or self-pay at scheduling, or logs a direct request for a written estimate.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Identify the patient as uninsured or self-pay"
        },
        {
          "detail": "List each planned service with its CDT code, description, and expected fee, using the current fee schedule.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Compile the itemized service list"
        },
        {
          "detail": "Confirm the estimate includes: itemized services and fees, the provider's name, a statement that the estimate is a good-faith estimate and not a guarantee, and notice of the patient's right to a dispute-resolution process if charges substantially exceed the estimate.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Confirm required good faith estimate elements"
        },
        {
          "detail": "Billing confirms the estimate meets the practice's required good-faith-estimate elements and delivery timeframe before it goes to the patient.\n\nWhy: A written estimate that is missing a required element is a compliance gap, not just an inconvenience — catching it before delivery is cheaper than fixing it after.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Compliance check before delivering the estimate.",
            "role": "billing",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "billing",
          "title": "Compliance check before delivering the estimate",
          "why": "A written estimate that is missing a required element is a compliance gap, not just an inconvenience — catching it before delivery is cheaper than fixing it after."
        },
        {
          "detail": "Provide the completed good faith estimate to the patient in writing no later than the No Surprises Act floor (45 CFR 149.610): 1 business day before a service scheduled 3–9 business days out, or 3 business days before a service scheduled 10 or more business days out. Practice/state policy may set an earlier delivery target via the delivery-timeframe method-editable field, but never later than this floor.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Deliver the estimate in writing"
        },
        {
          "detail": "Patient signs or otherwise confirms receipt of the written estimate.",
          "id": "s6",
          "kind": "step",
          "role": "patient",
          "title": "Patient acknowledges receipt"
        },
        {
          "detail": "Save the itemized estimate and the patient's acknowledgment of receipt in the patient's file with the delivery date.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "File the estimate and acknowledgment"
        },
        {
          "detail": "Good faith estimate delivered",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Good faith estimate delivered"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Good faith estimate for uninsured or self-pay patients — An uninsured or self-pay patient schedules a service or requests a written estimate.",
      "title": "Good faith estimate for uninsured or self-pay patients",
      "trigger": "An uninsured or self-pay patient schedules a service or requests a written estimate",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "tpf-006",
      "kind": "operational",
      "materials": [
        "payment options handout",
        "third-party financing application access",
        "in-house plan terms sheet"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "billing",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the patient portion the patient cannot pay in full today, based on the financial estimate already presented.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Identify the payment gap"
        },
        {
          "detail": "Present, in plain terms: pay-in-full at time of service, an in-house payment plan, and third-party financing (if the practice offers it), including any that carry a fee or interest.\n\nWhy: Presenting every option the practice actually offers — not steering toward one — keeps the conversation informational rather than a sales pitch.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the available options",
          "why": "Presenting every option the practice actually offers — not steering toward one — keeps the conversation informational rather than a sales pitch."
        },
        {
          "detail": "Patient selects an in-house plan, third-party financing, or asks for more time to decide.",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "in-house",
              "label": "In-house payment plan"
            },
            {
              "goto": "s7",
              "id": "third-party",
              "label": "Third-party financing"
            },
            {
              "goto": "s8",
              "id": "decide-later",
              "label": "Needs more time"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "patient",
          "title": "Patient chooses a path"
        },
        {
          "detail": "Hand off to the in-house payment plan setup and disclosure protocol.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Route to in-house plan setup"
        },
        {
          "detail": "Record which option was presented and chosen (or deferred) in the PMS.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the option chosen"
        },
        {
          "detail": "Payment options discussion complete",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Payment options discussion complete"
        },
        {
          "detail": "Provide access to the financing application; the decision and terms are between the patient and the financing company, not the practice.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Assist with the third-party financing application"
        },
        {
          "detail": "Add the patient to the follow-up cadence list rather than letting the decision drop.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Enter into follow-up cadence"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Presenting payment options and third-party financing — A patient cannot pay the patient portion in full at scheduling.",
      "title": "Presenting payment options and third-party financing",
      "trigger": "A patient cannot pay the patient portion in full at scheduling",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        },
        {
          "kind": "regulation",
          "label": "Reg Z applies to consumer credit repayable in more than four installments, or that carries a finance charge — both trigger written disclosure of the finance charge, APR, payment schedule and total of payments",
          "source": "Reg Z applies to consumer credit repayable in more than four installments, or that carries a finance charge — both trigger written disclosure of the finance charge, APR, payment schedule and total of payments",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "per-patient",
      "id": "tpf-007",
      "kind": "operational",
      "materials": [
        "in-house plan terms sheet",
        "Reg Z disclosure template",
        "autopay authorization form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "billing",
        "treatment-coordinator",
        "office-manager",
        "practice-owner",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "Work out the number of installments, amount per installment, and whether any finance charge applies.",
          "id": "s1",
          "kind": "step",
          "role": "billing",
          "title": "Determine proposed installment terms"
        },
        {
          "detail": "Check whether the proposed plan is more than four installments or carries a finance charge — either one triggers the Reg Z disclosure requirement.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "triggers-disclosure",
              "label": "Yes — Reg Z disclosure required"
            },
            {
              "goto": "s4",
              "id": "no-disclosure",
              "label": "No — four or fewer installments, no finance charge"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "More than four installments, or a finance charge?"
        },
        {
          "detail": "Office manager confirms the written disclosure states the finance charge (if any), APR, payment schedule and total of payments before the plan is offered to the patient.\n\nWhy: A plan that meets Reg Z's trigger conditions without the matching disclosure is a lending-law violation, not just a documentation gap.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Complete the written lending-law disclosure.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "office-manager",
          "title": "Complete the written lending-law disclosure",
          "why": "A plan that meets Reg Z's trigger conditions without the matching disclosure is a lending-law violation, not just a documentation gap."
        },
        {
          "detail": "Office manager or practice owner reviews and approves the final terms before the patient signs, particularly any non-standard terms.\n\nWhy: Money commitments spanning multiple months need a named approver, the same reason non-negotiable #4 keeps consequential decisions off auto-submit — here the generic functional equivalent is a supervisor sign-off rather than a licensed clinician.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor approves the plan terms.",
            "role": "office-manager or practice-owner",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Supervisor approves the plan terms",
          "why": "Money commitments spanning multiple months need a named approver, the same reason non-negotiable #4 keeps consequential decisions off auto-submit — here the generic functional equivalent is a supervisor sign-off rather than a licensed clinician."
        },
        {
          "detail": "Patient signs the payment plan agreement (with disclosure attached, if triggered) and the autopay authorization form.",
          "id": "s5",
          "kind": "step",
          "role": "patient",
          "title": "Patient signs the agreement and autopay authorization"
        },
        {
          "detail": "Enter the installment schedule and autopay method into the billing system and confirm the first charge date with the patient.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Set up the billing schedule"
        },
        {
          "detail": "Save the signed plan agreement, disclosure (if applicable), and autopay authorization in the patient's file.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "File the signed agreement"
        },
        {
          "detail": "In-house plan setup complete",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "In-house plan setup complete"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "In-house payment plan setup with written lending-law disclosure — The practice agrees to installments — terms, disclosures, autopay authorization and default rules are documented; more than four installments or a finance charge triggers the disclosure check.",
      "title": "In-house payment plan setup with written lending-law disclosure",
      "trigger": "The practice agrees to installments — terms, disclosures, autopay authorization and default rules are documented; more than four installments or a finance charge triggers the disclosure check",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "regulation",
          "label": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "source": "No Surprises Act good faith estimate for uninsured/self-pay, 45 CFR 149.610 (applicability to dental offices is contested — drafted as good practice)",
          "url": "https://www.ecfr.gov/current/title-45/section-149.610"
        },
        {
          "kind": "regulation",
          "label": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "source": "Truth in Lending Act / Regulation Z 12 CFR 1026 — in-house plans with more than four installments or a finance charge",
          "url": "https://www.ecfr.gov/current/title-12/part-1026"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "tpf-008",
      "kind": "operational",
      "materials": [
        "membership plan tiers/benefits sheet",
        "enrollment and payment authorization form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "front-desk",
        "office-manager",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Confirm the patient has no dental insurance and is asking about, or is a candidate for, the practice's membership plan.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Confirm the patient is uninsured and interested"
        },
        {
          "detail": "Walk through the available tiers, what's included (e.g. preventive visits), what's excluded, and the annual or monthly price.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the plan tiers and benefits"
        },
        {
          "detail": "Cover: this is not insurance, renewal terms, cancellation terms, and any state-required discount-medical-plan disclosure language.\n\nWhy: State discount-medical-plan statutes commonly require the plan to be clearly disclosed as not insurance — skipping this is the most common membership-plan compliance miss.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Cover required disclosures",
          "why": "State discount-medical-plan statutes commonly require the plan to be clearly disclosed as not insurance — skipping this is the most common membership-plan compliance miss."
        },
        {
          "detail": "Patient enrolls now, or wants to think about it.",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "enroll",
              "label": "Enroll now"
            },
            {
              "goto": "s10",
              "id": "later",
              "label": "Wants to think about it"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "patient",
          "title": "Patient decides"
        },
        {
          "detail": "A staff member other than the one who presented the plan (front desk or office manager) confirms the disclosed tier, price and renewal/cancellation terms match what will be entered into the PMS before the patient signs the recurring payment authorization.\n\nWhy: A recurring autopay commitment should not go straight from patient decision to PMS activation with no second set of eyes, matching the review step tpf-007's in-house payment plan and tpf-015's membership renewal/cancellation already require.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Staff review before a new recurring autopay membership is activated.",
            "role": "front-desk or office-manager",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "office-manager",
          "title": "Staff review before a new recurring autopay membership is activated",
          "why": "A recurring autopay commitment should not go straight from patient decision to PMS activation with no second set of eyes, matching the review step tpf-007's in-house payment plan and tpf-015's membership renewal/cancellation already require."
        },
        {
          "detail": "Patient signs the enrollment form and payment authorization for the chosen tier.",
          "id": "s6",
          "kind": "step",
          "role": "patient",
          "title": "Patient signs enrollment and payment authorization"
        },
        {
          "detail": "Enter the membership tier, start date, and payment method into the PMS so benefits are active at the front desk and chairside.",
          "id": "s7",
          "kind": "step",
          "role": "front-desk",
          "title": "Activate the membership in the PMS"
        },
        {
          "detail": "Record enrolled/deferred status, tier chosen (if enrolled), and date in the patient's file.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the enrollment outcome"
        },
        {
          "detail": "Membership enrollment process complete",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Membership enrollment process complete"
        },
        {
          "detail": "Note the patient's interest and add to a follow-up list rather than letting it drop.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Log the interest for follow-up"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "In-office membership plan enrollment — An uninsured patient is interested in the practice's membership plan.",
      "title": "In-office membership plan enrollment",
      "trigger": "An uninsured patient is interested in the practice's membership plan",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "open_standard",
          "label": "ADA Dental Claim Form structure, commonly reused for predetermination submissions (CDT coding standard)",
          "source": "ADA Dental Claim Form structure, commonly reused for predetermination submissions (CDT coding standard)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "per-patient",
      "id": "tpf-009",
      "kind": "operational",
      "materials": [
        "treatment plan with CDT codes",
        "insurance predetermination form or payer portal",
        "chart notes and radiographs to attach",
        "predetermination tracking log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "insurance-coordinator",
        "treatment-coordinator"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "After the dentist finalizes a treatment plan with major-treatment CDT codes (e.g. crowns, bridges, implants, perio surgery, ortho), the treatment coordinator flags the plan for predetermination review before it is scheduled.\n\nWhy: Submitting a predetermination before scheduling avoids surprising the patient with a denied or reduced benefit after treatment is already booked.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Identify treatment requiring predetermination",
          "why": "Submitting a predetermination before scheduling avoids surprising the patient with a denied or reduced benefit after treatment is already booked."
        },
        {
          "detail": "Check plan benefits: some payers require predetermination above a dollar threshold, some make it optional, some do not offer it at all.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "required",
              "label": "Plan requires or allows predetermination — submit"
            },
            {
              "goto": "s10",
              "id": "not-offered",
              "label": "Plan does not offer predetermination"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Does the patient's plan require or allow predetermination?"
        },
        {
          "detail": "Collect: proposed CDT codes and tooth/surface detail, current radiographs and periodontal charting where relevant, narrative of medical/dental necessity, patient insurance member ID and group number, provider NPI.",
          "id": "s3",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Gather predetermination documentation"
        },
        {
          "detail": "Submit through the payer portal, clearinghouse, or paper form per the payer's preferred channel; record the submission date and confirmation number in the tracking log.\n\nRecord: submission date, confirmation/reference number, payer, and codes submitted logged in the predetermination tracking log",
          "id": "s4",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Submit predetermination to payer"
        },
        {
          "detail": "Follow up with the payer if no response is received within the plan's typical turnaround window (commonly 2–4 weeks); log follow-up calls and reference numbers.\n\nWhy: Predeterminations expire and treatment can drift out of the benefit year if the office does not chase the response.",
          "id": "s5",
          "kind": "timer",
          "role": "insurance-coordinator",
          "timer_seconds": 1209600,
          "title": "Track payer turnaround",
          "why": "Predeterminations expire and treatment can drift out of the benefit year if the office does not chase the response."
        },
        {
          "detail": "Payer returns an approved, modified, or denied predetermination with the specific benefit amount and any conditions.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "approved",
              "label": "Approved as submitted — proceed to scheduling"
            },
            {
              "goto": "s12",
              "id": "modified",
              "label": "Approved with modification or partial denial"
            },
            {
              "goto": "s12",
              "id": "denied",
              "label": "Denied — appeal or replan"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "insurance-coordinator",
          "title": "Payer response received"
        },
        {
          "detail": "Insurance coordinator hands the final predetermination result and the patient's expected out-of-pocket portion to the treatment coordinator for financial arrangement and scheduling.",
          "id": "s7",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand predetermination result to treatment coordinator"
        },
        {
          "detail": "Log the approved codes, covered amount, patient portion, and predetermination expiration date in the patient's financial arrangement record.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Record predetermination outcome in the patient's financial file"
        },
        {
          "detail": "Treatment is ready to schedule with a documented, payer-confirmed or good-faith cost estimate.",
          "id": "s9",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Predetermination cycle complete"
        },
        {
          "detail": "Build a written estimate from the fee schedule and the patient's known benefit percentages, labeled as an estimate, and route to the cost-estimate handoff below.\n\nWhy: A patient still deserves a written cost expectation even when the payer will not pre-adjudicate.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Prepare a good-faith estimate instead",
          "why": "A patient still deserves a written cost expectation even when the payer will not pre-adjudicate."
        },
        {
          "detail": "Insurance coordinator hands the written good-faith estimate to the treatment coordinator to present alongside the treatment plan.",
          "id": "s11",
          "kind": "step",
          "role": "insurance-coordinator",
          "title": "Hand estimate to treatment coordinator for presentation"
        },
        {
          "detail": "Bring the payer's modification or denial reasoning back to the dentist to decide whether to appeal, adjust the plan, or proceed with an updated patient-portion estimate.\n\nWhy: Only the treating dentist can decide whether a clinically necessary plan changes based on what the payer will cover.",
          "id": "s12",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Review modified or denied response with the dentist",
          "why": "Only the treating dentist can decide whether a clinically necessary plan changes based on what the payer will cover."
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Predetermination / pre-treatment estimate submission — Major treatment is planned for an insured patient and the plan allows or requires a predetermination.",
      "title": "Predetermination / pre-treatment estimate submission",
      "trigger": "Major treatment is planned for an insured patient and the plan allows or requires a predetermination",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 25,
      "frequency": "per-patient",
      "id": "tpf-010",
      "kind": "operational",
      "materials": [
        "full treatment plan with CDT codes and fees",
        "benefit-year calendar for the patient's plan",
        "phased-treatment agreement template",
        "scheduling system"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "dentist",
        "scheduler",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Read the complete plan and priority order the dentist set (urgent/disease-control items first, then restorative, then elective).\n\nWhy: Phasing must follow clinical priority, not just cost convenience — the dentist's sequence is the clinical floor phasing works within.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Review the dentist's full treatment plan",
          "why": "Phasing must follow clinical priority, not just cost convenience — the dentist's sequence is the clinical floor phasing works within."
        },
        {
          "detail": "Group procedures into phases by clinical priority, benefit-year timing (to maximize insurance use across two plan years), and the patient's stated budget capacity discussed at presentation.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Propose a phase split with the dentist"
        },
        {
          "detail": "The treating dentist confirms that splitting treatment into the proposed phases does not create an unsafe gap (e.g. leaving active disease untreated too long) before the plan is presented to the patient.\n\nWhy: A phase split proposed for financial convenience must never be allowed to delay urgent or disease-control treatment without the dentist's clinical confirmation.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist confirms phase groupings are clinically sound.",
            "role": "treating dentist",
            "type": "licensed"
          },
          "id": "s3",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist confirms phase groupings are clinically sound",
          "why": "A phase split proposed for financial convenience must never be allowed to delay urgent or disease-control treatment without the dentist's clinical confirmation."
        },
        {
          "detail": "Walk the patient through each phase: what is done, why that phase, approximate timing, and the payment due at that phase.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the phased plan to the patient"
        },
        {
          "detail": "Patient reviews and either agrees to the proposed sequence or asks to reorder/adjust phases within what the dentist confirmed is clinically safe.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "accept",
              "label": "Patient accepts the proposed sequence"
            },
            {
              "goto": "s2",
              "id": "reorder",
              "label": "Patient requests a different order or timing"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "patient",
          "title": "Patient accepts the phased sequence"
        },
        {
          "detail": "Record each phase's procedures, target date range, and payment amount in a written phased-treatment agreement; obtain patient signature or documented verbal agreement.\n\nRecord: phased-treatment agreement with phase dates, codes, and payment amounts in the patient's financial file",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the phased-treatment agreement"
        },
        {
          "detail": "Hand the confirmed Phase 1 procedures and target date to the scheduler to book the next appointment.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand Phase 1 to scheduling"
        },
        {
          "detail": "Set a follow-up reminder ahead of each unscheduled phase's target window so the office proactively reaches out rather than waiting for the patient to call.\n\nWhy: Phased plans lose momentum without a proactive nudge — see the dormant-treatment follow-up protocol for the systematic version of this check.",
          "id": "s8",
          "kind": "step",
          "role": "scheduler",
          "title": "Set reminders for subsequent phases",
          "why": "Phased plans lose momentum without a proactive nudge — see the dormant-treatment follow-up protocol for the systematic version of this check."
        },
        {
          "detail": "After each phase is completed, mark it done in the phased-treatment agreement and confirm the next phase's timing still holds against the benefit-year calendar.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Track phase completion against the plan"
        },
        {
          "detail": "All phases are scheduled or reminder-tracked, with a signed agreement on file.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Phased plan documented and in motion"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Phased treatment sequencing agreed with the patient — A plan is accepted in phases — phase dates, benefits-year timing and payment per phase are recorded.",
      "title": "Phased treatment sequencing agreed with the patient",
      "trigger": "A plan is accepted in phases — phase dates, benefits-year timing and payment per phase are recorded",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 10,
      "frequency": "per-patient",
      "id": "tpf-011",
      "kind": "operational",
      "materials": [
        "presented treatment plan with cost estimate",
        "follow-up cadence tracker (call/text/email log)",
        "patient education materials relevant to the plan",
        "unscheduled-treatment list"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "At the end of the visit, enter the plan, its cost, and the patient's stated reason for wanting to think about it (cost, timing, need to consult a spouse, need to compare, none given) into the follow-up tracker.\n\nWhy: Capturing the stated reason lets the follow-up touch address the actual objection instead of a generic reminder.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Log the plan as presented-not-accepted",
          "why": "Capturing the stated reason lets the follow-up touch address the actual objection instead of a generic reminder."
        },
        {
          "detail": "Schedule the standard touch sequence: first touch at 2–3 days (recap + answer questions), second touch at 2 weeks (financing options reminder), third touch at 6 weeks (clinical urgency check-in), unless the patient asked for a specific timeframe.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Set the follow-up cadence"
        },
        {
          "detail": "Contact the patient by their preferred channel, recap the plan and cost, and ask if they have questions; offer to walk through financing or phasing options.\n\nRecord: date, channel, and outcome of the touch logged in the follow-up tracker",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "First follow-up touch"
        },
        {
          "detail": "Patient response to first touch",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accepts1",
              "label": "Patient accepts — proceed to schedule"
            },
            {
              "goto": "s7",
              "id": "declines1",
              "label": "Patient declines outright"
            },
            {
              "goto": "s8",
              "id": "still-thinking1",
              "label": "Still thinking — continue cadence"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "patient",
          "title": "Patient response to first touch"
        },
        {
          "detail": "Hand the accepted plan to the scheduler to book the appointment and to billing to confirm the financial arrangement.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand accepted plan to scheduling"
        },
        {
          "detail": "Plan is scheduled, declined-and-logged, or moved to the dormant list.",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Follow-up cadence resolved"
        },
        {
          "detail": "Record the plan as declined with the reason given, and remove it from active follow-up while keeping it available for future re-presentation at recall.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Log outcome as declined"
        },
        {
          "detail": "Reach out again per cadence, this time leading with financing or payment-plan options relevant to the plan's cost.\n\nRecord: date, channel, and outcome logged",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Second follow-up touch"
        },
        {
          "detail": "Patient response to second touch",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accepts2",
              "label": "Patient accepts — proceed to schedule"
            },
            {
              "goto": "s7",
              "id": "declines2",
              "label": "Patient declines outright"
            },
            {
              "goto": "s10",
              "id": "still-thinking2",
              "label": "Still thinking — continue cadence"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "patient",
          "title": "Patient response to second touch"
        },
        {
          "detail": "Final scheduled touch — check in on any clinical urgency the dentist flagged, and offer a brief call with the dentist if questions remain clinical rather than financial.\n\nRecord: date, channel, and outcome logged",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Third follow-up touch"
        },
        {
          "detail": "Patient response to third touch",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "accepts3",
              "label": "Patient accepts — proceed to schedule"
            },
            {
              "goto": "s12",
              "id": "no-response",
              "label": "No response after full cadence"
            }
          ],
          "id": "s11",
          "kind": "fork",
          "role": "patient",
          "title": "Patient response to third touch"
        },
        {
          "detail": "Hand the unresponsive plan to the dormant/unscheduled-treatment follow-up protocol's monthly review rather than continuing ad hoc outreach.",
          "id": "s12",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Move to the dormant treatment follow-up list"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Patient wants to think about it — follow-up cadence — A plan is presented and not accepted at the visit.",
      "title": "Patient wants to think about it — follow-up cadence",
      "trigger": "A plan is presented and not accepted at the visit",
      "trigger_kind": "routine",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "generic",
          "label": "Insurer contract terms generally prohibit routine copay/coinsurance waiver as it constitutes fee misrepresentation to the payer — standard payer-contract clause, cited generically as no single public source covers all payers",
          "source": "Insurer contract terms generally prohibit routine copay/coinsurance waiver as it constitutes fee misrepresentation to the payer — standard payer-contract clause, cited generically as no single public source covers all payers"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "as-needed",
      "id": "tpf-012",
      "kind": "operational",
      "materials": [
        "standard fee schedule",
        "discount/hardship approval log",
        "insurance contract terms (for copay-waiver restrictions)",
        "written discount policy, if the practice has one"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "billing",
        "practice-owner",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "A staff member — treatment coordinator or billing — identifies a situation warranting a discount, courtesy adjustment, or hardship reduction (e.g. financial hardship, staff/family courtesy, goodwill for a service issue, multi-procedure bundling).",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Staff identifies a reason for a non-standard fee"
        },
        {
          "detail": "Routine waiver of a patient's contractual copay or coinsurance can violate the practice's payer contract terms, separate from any hardship consideration.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "no-copay",
              "label": "No copay/coinsurance involved — standard fee discount"
            },
            {
              "goto": "s9",
              "id": "copay-involved",
              "label": "Request involves waiving an insurance copay/coinsurance"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "Does the request involve waiving an insurance copay or coinsurance?"
        },
        {
          "detail": "Record the patient, the treatment, the standard fee, the proposed reduced fee or waived amount, and the specific reason (hardship documentation, courtesy category, or goodwill reason) in the discount/hardship log.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the request and rationale"
        },
        {
          "detail": "No discount, courtesy adjustment, hardship reduction, or copay waiver is applied to the ledger until the practice owner (or their explicitly delegated approver) reviews the documented request and signs off, in writing or in the practice management system.\n\nWhy: Discounting is a financial-control point (this repo's non-negotiables reserve money decisions for a supervisor sign-off): unapproved discounts erode production tracking, can create inconsistent-treatment-of-patients risk, and — for copay waivers — payer-contract risk.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner or delegated approver signs off before the discount is applied.",
            "role": "practice owner or office manager holding delegated discount authority",
            "type": "licensed"
          },
          "id": "s4",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner or delegated approver signs off before the discount is applied",
          "why": "Discounting is a financial-control point (this repo's non-negotiables reserve money decisions for a supervisor sign-off): unapproved discounts erode production tracking, can create inconsistent-treatment-of-patients risk, and — for copay waivers — payer-contract risk."
        },
        {
          "detail": "Approver decision",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "approved",
              "label": "Approved as requested"
            },
            {
              "goto": "s6",
              "id": "modified",
              "label": "Approved at a different amount"
            },
            {
              "goto": "s10",
              "id": "denied",
              "label": "Denied"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Approver decision"
        },
        {
          "detail": "Enter the approved discount or waiver amount against the specific procedures in the ledger, referencing the approval log entry so the write-off is traceable.\n\nRecord: approved discount amount, approver, date, and reason posted to the patient ledger with a reference to the approval log",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Apply the approved adjustment to the account"
        },
        {
          "detail": "Provide the patient a written or verbal confirmation of the adjusted fee and, if it is a one-time courtesy rather than an ongoing arrangement, note that clearly so it is not expected at future visits.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Communicate the adjusted fee to the patient"
        },
        {
          "detail": "Ledger reflects only owner-approved adjustments, fully traceable to the approval log.",
          "id": "s8",
          "kind": "step",
          "role": "billing",
          "title": "Discount request resolved"
        },
        {
          "detail": "Review the practice's contract with the relevant payer for copay-waiver restrictions; routine waiver without documented hardship can constitute misrepresentation to the insurer.\n\nWhy: A copay waiver that is not a genuine, documented hardship can put the practice's payer contract and billing integrity at risk.",
          "id": "s9",
          "kind": "step",
          "role": "billing",
          "title": "Check payer contract terms before proceeding",
          "why": "A copay waiver that is not a genuine, documented hardship can put the practice's payer contract and billing integrity at risk."
        },
        {
          "detail": "Inform the requesting staff and, where appropriate, the patient that the discount was not approved, and discuss standard payment-plan or phasing alternatives instead.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Communicate the denial and alternatives"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Discount, courtesy, hardship or fee-reduction approval — Staff proposes a non-standard fee, a copay waiver or a hardship discount for a patient.",
      "title": "Discount, courtesy, hardship or fee-reduction approval",
      "trigger": "Staff proposes a non-standard fee, a copay waiver or a hardship discount for a patient",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 45,
      "frequency": "weekly",
      "id": "tpf-013",
      "kind": "operational",
      "materials": [
        "practice management system unscheduled-treatment report",
        "dormant-treatment list (90+ days untouched)",
        "outreach script/templates",
        "call/text/email log"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "scheduler",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Run the practice management system report for treatment marked accepted-but-unscheduled and presented-but-undecided, sorted by dollar value and date presented.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Pull the weekly unscheduled-treatment report"
        },
        {
          "detail": "Flag any items the dentist marked clinically time-sensitive first, then work the remainder oldest-first.\n\nWhy: A patient with disease-control treatment sitting unscheduled is a different priority than an elective item that simply has not been booked yet.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Triage the list by urgency and age",
          "why": "A patient with disease-control treatment sitting unscheduled is a different priority than an elective item that simply has not been booked yet."
        },
        {
          "detail": "Call, text, or email each patient using the practice's preferred-contact method, referencing the specific treatment and offering to schedule.\n\nRecord: date, channel, and outcome logged against each list item",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Contact each patient on the list"
        },
        {
          "detail": "Outreach outcome",
          "forks": [
            {
              "advised": true,
              "goto": "s5",
              "id": "scheduled",
              "label": "Patient schedules"
            },
            {
              "goto": "s9",
              "id": "not-reached",
              "label": "Not reached this cycle"
            },
            {
              "goto": "s10",
              "id": "declines",
              "label": "Patient no longer wants the treatment"
            }
          ],
          "id": "s4",
          "kind": "fork",
          "role": "patient",
          "title": "Outreach outcome"
        },
        {
          "detail": "Confirm the appointment is booked in the scheduling system and remove the item from next week's list.",
          "id": "s5",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand scheduled item to the scheduler for booking confirmation"
        },
        {
          "detail": "On the monthly cycle, in addition to the weekly run, check for any item untouched (no outreach, no response) for 90 or more days.",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "monthly-due",
              "label": "Monthly sweep is due"
            },
            {
              "goto": "s8",
              "id": "not-due",
              "label": "Not the monthly cycle"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "Monthly dormant sweep due?"
        },
        {
          "detail": "Decide, item by item, whether to attempt a final re-presentation touch, archive the plan, or flag it for the dentist to reconfirm clinical relevance at the patient's next recall visit.",
          "id": "s7",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Review the 90-day dormant list with the treatment coordinator lead"
        },
        {
          "detail": "List is worked, outcomes logged, and the dormant sweep is current.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Weekly/monthly follow-up cycle complete"
        },
        {
          "detail": "Item remains on the working list; increment its age counter for the monthly dormant check.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Keep item on next week's list"
        },
        {
          "detail": "Remove from the active list and note the decline reason; the item remains available for future re-presentation.",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Close the item as declined"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Unscheduled and dormant treatment follow-up list — Weekly run of accepted-but-unscheduled and presented-but-undecided treatment; monthly run of plans untouched for 90 days.",
      "title": "Unscheduled and dormant treatment follow-up list",
      "trigger": "Weekly run of accepted-but-unscheduled and presented-but-undecided treatment; monthly run of plans untouched for 90 days",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "weekly",
      "id": "tpf-014",
      "kind": "operational",
      "materials": [
        "practice management system production/case-acceptance report",
        "case acceptance tracking spreadsheet or dashboard",
        "prior weeks' figures for trend comparison"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 1,
      "steps": [
        {
          "detail": "Export dollars and counts of treatment presented, accepted, scheduled, and completed for the week, broken out by provider.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Pull the week's presentation-to-completion figures"
        },
        {
          "detail": "Calculate accepted-dollars ÷ presented-dollars per provider, and compare against the prior 4-week rolling average.\n\nWhy: A single week's number is noisy; the rolling trend is what actually signals a presentation-process problem worth addressing.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Compute case acceptance rate and trend",
          "why": "A single week's number is noisy; the rolling trend is what actually signals a presentation-process problem worth addressing."
        },
        {
          "detail": "Enter the week's figures into the tracking spreadsheet or dashboard so the trend line stays current.",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Update the case acceptance tracking dashboard"
        },
        {
          "detail": "Walk through the dashboard together: flag any provider or category with a declining acceptance rate, and review the unscheduled/dormant list (tpf-013) for overlap.",
          "id": "s4",
          "kind": "step",
          "role": "office-manager",
          "title": "Weekly review with office manager"
        },
        {
          "detail": "Decide whether the acceptance rate or unscheduled dollar value has moved enough to warrant a specific follow-up (e.g. coaching on presentation, a financing-option review, or an owner conversation about fees).",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "no-action",
              "label": "Trend is stable — no action needed"
            },
            {
              "goto": "s7",
              "id": "action-needed",
              "label": "Trend warrants a follow-up action"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the trend warrant a follow-up action?"
        },
        {
          "detail": "Dashboard is current and any needed follow-up action is assigned.",
          "id": "s6",
          "kind": "step",
          "role": "office-manager",
          "title": "Weekly case acceptance review complete"
        },
        {
          "detail": "Assign a specific, dated follow-up (e.g. treatment coordinator to shadow a presentation, review financing-option scripting, or escalate a fee-related pattern to the practice owner) and note it for review the following week.",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Assign a follow-up action"
        },
        {
          "detail": "A pattern of declined cases tied to price, or a pattern of discounting outside the approved process (tpf-012), should reach the practice owner.",
          "forks": [
            {
              "goto": "s9",
              "id": "owner-needed",
              "label": "Escalate to practice owner"
            },
            {
              "advised": true,
              "goto": "s6",
              "id": "internal-only",
              "label": "Handled within the front-office team"
            }
          ],
          "id": "s8",
          "kind": "fork",
          "role": "office-manager",
          "title": "Does the finding involve a fee or discount pattern requiring the owner?"
        },
        {
          "detail": "Summarize the trend and proposed action and hand it to the practice owner for a decision, referencing the discount-approval protocol (tpf-012) if relevant.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Hand the finding to the practice owner"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Case acceptance tracking and weekly review — Weekly — presented, accepted, scheduled and completed dollars and counts by provider.",
      "title": "Case acceptance tracking and weekly review",
      "trigger": "Weekly — presented, accepted, scheduled and completed dollars and counts by provider",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        },
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 20,
      "frequency": "as-needed",
      "id": "tpf-015",
      "kind": "operational",
      "materials": [
        "membership plan terms and pricing",
        "member roster with renewal dates and autopay status",
        "proration calculation worksheet",
        "cancellation/refund log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "billing",
        "office-manager",
        "patient"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Determine whether this is a scheduled annual renewal, a member-initiated mid-term cancellation, or an autopay dispute.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "renewal",
              "label": "Annual renewal due"
            },
            {
              "goto": "s6",
              "id": "cancellation",
              "label": "Member requests mid-term cancellation"
            },
            {
              "goto": "s11",
              "id": "dispute",
              "label": "Autopay charge disputed"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "What triggered this workflow?"
        },
        {
          "detail": "Notify the member of the upcoming renewal, current pricing, and any plan changes, per the plan terms' required notice period.",
          "id": "s2",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Send renewal notice ahead of the renewal date"
        },
        {
          "detail": "Member response to renewal notice",
          "forks": [
            {
              "advised": true,
              "goto": "s4",
              "id": "renews",
              "label": "Member renews (no action or confirms)"
            },
            {
              "goto": "s6",
              "id": "opts-out",
              "label": "Member opts out of renewal"
            }
          ],
          "id": "s3",
          "kind": "fork",
          "role": "patient",
          "title": "Member response to renewal notice"
        },
        {
          "detail": "Update the member's plan year and renewal date, and confirm the next autopay charge date and amount.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Process the renewal"
        },
        {
          "detail": "Member status, any refund, and the reason are recorded.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "Renewal, cancellation, or dispute resolved"
        },
        {
          "detail": "Confirm the member's intent to cancel and record the stated reason; note remaining plan benefits used vs unused.",
          "id": "s6",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Confirm cancellation and reason"
        },
        {
          "detail": "Apply the plan's proration formula to determine any refund owed for the unused portion of a prepaid term, netting out the value of services already used against member pricing.\n\nWhy: Membership plans are prepaid discount arrangements — an accurate proration protects both the member from being overcharged and the practice from over-refunding services already delivered at member rates.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Calculate proration or refund owed",
          "why": "Membership plans are prepaid discount arrangements — an accurate proration protects both the member from being overcharged and the practice from over-refunding services already delivered at member rates."
        },
        {
          "detail": "No refund is issued and no cancellation is finalized until the office manager reviews the proration calculation and approves the amount.\n\nWhy: Refunds are a financial-control point; an unreviewed refund calculation can misstate the value of services already delivered at discounted member pricing.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Office manager approves the refund or cancellation terms.",
            "role": "office manager",
            "type": "licensed"
          },
          "id": "s8",
          "kind": "gate",
          "role": "office-manager",
          "title": "Office manager approves the refund or cancellation terms",
          "why": "Refunds are a financial-control point; an unreviewed refund calculation can misstate the value of services already delivered at discounted member pricing."
        },
        {
          "detail": "Office manager decision",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "approved",
              "label": "Approved as calculated"
            },
            {
              "goto": "s10",
              "id": "adjusted",
              "label": "Approved with an adjusted amount"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Office manager decision"
        },
        {
          "detail": "Issue the approved refund via the original payment method where possible, cancel the autopay, and update the member roster status to cancelled.\n\nRecord: cancellation date, refund amount, approver, and reason posted to the cancellation/refund log",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Process the refund and finalize cancellation"
        },
        {
          "detail": "Pull the member's plan terms, autopay history, and any usage since the last charge to determine whether the charge was correct.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Review the disputed autopay charge"
        },
        {
          "detail": "Dispute finding",
          "forks": [
            {
              "advised": true,
              "goto": "s13",
              "id": "charge-correct",
              "label": "Charge was correct — explain to member"
            },
            {
              "goto": "s7",
              "id": "charge-error",
              "label": "Charge was an error"
            }
          ],
          "id": "s12",
          "kind": "fork",
          "role": "billing",
          "title": "Dispute finding"
        },
        {
          "detail": "Walk the member through the plan terms and the specific charge so the dispute is resolved with a clear explanation on file.",
          "id": "s13",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Explain the charge to the member"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Membership plan renewal, cancellation and proration refund — A member's annual renewal is due, or a member cancels mid-term or disputes the autopay.",
      "title": "Membership plan renewal, cancellation and proration refund",
      "trigger": "A member's annual renewal is due, or a member cancels mid-term or disputes the autopay",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "tpf-016",
      "kind": "operational",
      "materials": [
        "practice's written charity-care/sliding-scale policy, if one exists",
        "income/hardship self-attestation or documentation form",
        "sliding-scale fee table",
        "charity-care approval and tracking log"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "treatment-coordinator",
        "practice-owner",
        "billing"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "After presenting the treatment plan and reviewing standard fees, payment plans, and any general discount policy, the patient states they cannot afford care at any level offered.",
          "id": "s1",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Identify the patient cannot pay at any offered level"
        },
        {
          "detail": "Confirm whether the practice maintains a written charity-care or sliding-scale program, versus case-by-case pro-bono decisions made by the owner.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "has-program",
              "label": "Practice has a documented program — apply it"
            },
            {
              "goto": "s11",
              "id": "no-program",
              "label": "No formal program — case-by-case owner decision"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "treatment-coordinator",
          "title": "Does the practice have a charity-care/sliding-scale program?"
        },
        {
          "detail": "Collect what the program requires: household size and income self-attestation or documentation, and confirm the treatment requested falls within the program's eligible scope (e.g. urgent/pain-relief items vs elective).",
          "id": "s3",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Collect eligibility documentation"
        },
        {
          "detail": "Determine the patient's fee tier from the sliding-scale table based on the documented household income and size, and calculate the adjusted fee for the eligible treatment.",
          "id": "s4",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Apply the sliding-scale fee table"
        },
        {
          "detail": "No charity-care, sliding-scale, or pro-bono adjustment is finalized until the practice owner reviews the eligibility documentation or case summary and approves the fee level and scope of treatment covered.\n\nWhy: Charity-care decisions commit practice resources and set a precedent for future requests; owner sign-off keeps the program consistent and within the practice's actual capacity to absorb unpaid care.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner approves charity-care or pro-bono eligibility.",
            "role": "practice owner",
            "type": "licensed"
          },
          "id": "s5",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner approves charity-care or pro-bono eligibility",
          "why": "Charity-care decisions commit practice resources and set a precedent for future requests; owner sign-off keeps the program consistent and within the practice's actual capacity to absorb unpaid care."
        },
        {
          "detail": "Owner decision",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "approved",
              "label": "Approved at the calculated or proposed level"
            },
            {
              "goto": "s7",
              "id": "modified",
              "label": "Approved at a different fee level or reduced scope"
            },
            {
              "goto": "s12",
              "id": "denied",
              "label": "Not approved"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "practice-owner",
          "title": "Owner decision"
        },
        {
          "detail": "Record the approved fee level, scope of treatment covered, approver, and date in the charity-care log and the patient's financial file.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Document the approved arrangement"
        },
        {
          "detail": "Explain the approved fee and scope of care to the patient, and whether the arrangement is a one-time case or an ongoing sliding-scale status for future visits.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Communicate the arrangement to the patient"
        },
        {
          "detail": "Hand the approved, priced plan to the scheduler to book treatment.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Hand approved plan to scheduling"
        },
        {
          "detail": "Decision, approver, and terms are documented in the charity-care log.",
          "id": "s10",
          "kind": "step",
          "role": "billing",
          "title": "Charity-care eligibility decision resolved"
        },
        {
          "detail": "Summarize the treatment needed, the patient's stated hardship, and any documentation available, for the practice owner to consider as a one-off pro-bono or partial-fee case.",
          "id": "s11",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Prepare a case summary for the owner"
        },
        {
          "detail": "Inform the patient of the outcome and discuss any remaining alternatives (payment plan, phasing, or referral to a community/dental-school clinic resource).",
          "id": "s12",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Communicate the outcome and alternatives"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Charity-care, sliding-scale and pro-bono eligibility and documentation — A patient cannot pay at any level and the practice's charity or sliding-scale program is considered.",
      "title": "Charity-care, sliding-scale and pro-bono eligibility and documentation",
      "trigger": "A patient cannot pay at any level and the practice's charity or sliding-scale program is considered",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 30,
      "frequency": "as-needed",
      "id": "tpf-017",
      "kind": "operational",
      "materials": [
        "practice written warranty policy (window, exclusions, materials covered)",
        "original treatment record and chart notes",
        "photo or radiograph of the failure",
        "redo/remake authorization form"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "dentist",
        "treatment-coordinator",
        "office-manager",
        "front-desk"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record the patient's description of what failed (crown came off, filling chipped, denture cracked), the date of the original procedure if known, and whether pain or a broken edge poses any immediate risk.\n\nWhy: A dated, specific record is what lets the dentist later apply the warranty window fairly instead of relying on memory.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Log the failure complaint",
          "why": "A dated, specific record is what lets the dentist later apply the warranty window fairly instead of relying on memory."
        },
        {
          "detail": "Route based on symptoms described, not on warranty status — warranty is a billing question, not a triage question.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "urgent",
              "label": "Urgent symptoms present"
            },
            {
              "goto": "s11",
              "id": "routine",
              "label": "No urgent symptoms"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Is this urgent (pain, sharp edge, swallowing risk)?"
        },
        {
          "detail": "Book the patient into the day's emergency or buffer slot regardless of warranty status; financial resolution happens after the dentist has seen the tooth.\n\nWhy: Clinical response is never held up by a billing decision.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Offer a same-day or next-available emergency slot",
          "why": "Clinical response is never held up by a billing decision."
        },
        {
          "detail": "Take a photo or radiograph of the failed restoration, compare against the original treatment note, and record a probable cause: material/workmanship failure, new decay, trauma, bruxism, or patient neglect (e.g. chewing ice, missed hygiene).\n\nWhy: Cause determines whether the warranty applies — a warranty covers the restoration's own failure, not a new problem or external trauma.\n\nRecord: clinical exam note with probable cause and supporting image",
          "id": "s4",
          "kind": "step",
          "role": "dentist",
          "title": "Examine the failure and document cause",
          "why": "Cause determines whether the warranty applies — a warranty covers the restoration's own failure, not a new problem or external trauma."
        },
        {
          "detail": "Compare the failure date against the practice's written warranty policy and the documented exclusions.",
          "forks": [
            {
              "advised": true,
              "goto": "s6",
              "id": "covered",
              "label": "Within window, cause is covered"
            },
            {
              "goto": "s12",
              "id": "excluded",
              "label": "Excluded (trauma, neglect, new decay) or outside window"
            }
          ],
          "id": "s5",
          "kind": "fork",
          "role": "dentist",
          "title": "Does the failure fall within the stated warranty window and is it not on the exclusion list?"
        },
        {
          "detail": "The dentist confirms in writing (or in the chart) that the remake is warranty-covered and authorizes the treatment coordinator to schedule it at no charge to the patient.\n\nWhy: A financial write-off tied to a clinical judgment call is never auto-approved by front-office staff alone.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Dentist sign-off on no-charge remake.",
            "role": "dentist",
            "type": "licensed"
          },
          "id": "s6",
          "kind": "gate",
          "role": "dentist",
          "title": "Dentist sign-off on no-charge remake",
          "why": "A financial write-off tied to a clinical judgment call is never auto-approved by front-office staff alone."
        },
        {
          "detail": "Dentist tells the treatment coordinator the remake is approved at no charge, names the procedure code(s) to zero out, and any lab or material cost the practice will absorb.",
          "id": "s7",
          "kind": "step",
          "role": "dentist",
          "title": "Hand off approved remake to the treatment coordinator"
        },
        {
          "detail": "Book the remake appointment, set the ledger entry for the redo procedure to $0 patient responsibility, and note 'warranty redo, no charge' with the original procedure date referenced.",
          "id": "s8",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Schedule the remake and zero the patient portion"
        },
        {
          "detail": "File the warranty decision against both the clinical chart and the billing ledger so future staff can see why the charge was zeroed or applied.\n\nRecord: Decision (covered/excluded), cause, dentist sign-off if covered, and the final fee or $0 charge, filed against both the clinical chart and the ledger.",
          "id": "s9",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Document the outcome in the patient's financial and clinical record"
        },
        {
          "detail": "Warranty decision closed",
          "id": "s10",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Warranty decision closed"
        },
        {
          "detail": "Book a short exam visit within the practice's normal scheduling window to look at the failure before any warranty decision is made.",
          "id": "s11",
          "kind": "step",
          "role": "front-desk",
          "title": "Schedule a clinical evaluation visit"
        },
        {
          "detail": "Explain plainly why the failure falls outside the warranty (cause, or elapsed time past the window), then present the fee for redoing the restoration as a new procedure, including any goodwill discount the dentist has approved.\n\nWhy: Patients accept a denial better when they hear the specific reason, not just 'no.'",
          "id": "s12",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Present the excluded case as a new paid treatment",
          "why": "Patients accept a denial better when they hear the specific reason, not just 'no.'"
        },
        {
          "detail": "Office manager weighs patient tenure, referral value, and case size against the dentist's guidance on goodwill discounts.",
          "forks": [
            {
              "advised": true,
              "goto": "s14",
              "id": "no-discount",
              "label": "Present full fee as normal treatment"
            },
            {
              "goto": "s15",
              "id": "goodwill",
              "label": "Offer a goodwill discount"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "office-manager",
          "title": "Offer a goodwill partial discount outside the warranty?"
        },
        {
          "detail": "Book the appointment and record the agreed fee, discount if any, and the reason on the treatment plan.",
          "id": "s14",
          "kind": "step",
          "role": "treatment-coordinator",
          "title": "Schedule the paid or discounted remake"
        },
        {
          "detail": "Office manager or practice owner approves the specific discount percentage or dollar amount before it is quoted to the patient.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor sign-off on goodwill discount amount.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s15",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor sign-off on goodwill discount amount"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Restoration warranty, redo and no-charge remake decision — A restoration fails within the practice's stated guarantee window and the patient asks for a free redo.",
      "title": "Restoration warranty, redo and no-charge remake decision",
      "trigger": "A restoration fails within the practice's stated guarantee window and the patient asks for a free redo",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 25,
      "frequency": "as-needed",
      "id": "tpf-018",
      "kind": "operational",
      "materials": [
        "custody or divorce decree (if provided) naming financial responsibility",
        "guarantor split agreement form",
        "practice financial policy",
        "ledger with split-billing capability"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "Record which parent contacted the office, whether they are disputing an existing bill or asking to set up billing before treatment, and whether they mention a custody order.",
          "id": "s1",
          "kind": "step",
          "role": "front-desk",
          "title": "Note who raised the payment question and what they're asking"
        },
        {
          "detail": "Ask the parent to send a copy of the relevant page if one exists; do not accept a verbal claim alone as proof.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "has-order",
              "label": "Decree provided naming responsibility"
            },
            {
              "goto": "s8",
              "id": "no-order",
              "label": "No order provided or none exists"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "front-desk",
          "title": "Has a custody or divorce decree been provided naming who pays?"
        },
        {
          "detail": "Office manager reads the relevant clause to confirm it actually names financial responsibility for dental/medical expenses (not just general custody terms), and notes any percentage split stated.\n\nWhy: Custody documents often address who has decision-making authority separately from who pays — the two are not the same clause.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Review the decree language with the office manager",
          "why": "Custody documents often address who has decision-making authority separately from who pays — the two are not the same clause."
        },
        {
          "detail": "Enter the named guarantor(s) and the split percentage from the decree into the ledger, attaching a copy of the relevant page to the account file.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Set up the account per the decree"
        },
        {
          "detail": "Tell both parents plainly that the practice will bill according to the decree's stated split but cannot act as a court, mediate the underlying dispute, or chase one parent to reimburse the other — collection between parents is between them.\n\nWhy: Sets an honest boundary that prevents the front desk from being drawn into ongoing parental conflict.",
          "id": "s5",
          "kind": "step",
          "role": "office-manager",
          "title": "State the practice's limited role in enforcement",
          "why": "Sets an honest boundary that prevents the front desk from being drawn into ongoing parental conflict."
        },
        {
          "detail": "File the finalized guarantor split and its basis in the account notes so any future billing question can be resolved without re-litigating it.\n\nRecord: Which parent(s) are guarantor of record, the split percentage if any, the basis (court order or written agreement), and a note of any unresolved dispute, filed in the account notes.",
          "id": "s6",
          "kind": "step",
          "role": "billing",
          "title": "Document the final guarantor arrangement"
        },
        {
          "detail": "Guarantor arrangement established",
          "id": "s7",
          "kind": "step",
          "role": "office-manager",
          "title": "Guarantor arrangement established"
        },
        {
          "detail": "Without a court order, the practice's default policy applies: typically the parent who brought the child to the visit and signed the treatment consent is the primary guarantor of record, unless both parents agree in writing to split.\n\nWhy: A consistent default avoids the front desk arbitrating a family dispute on the fly.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Explain the practice's default guarantor policy",
          "why": "A consistent default avoids the front desk arbitrating a family dispute on the fly."
        },
        {
          "detail": "Do both parents agree in writing to split the bill?",
          "forks": [
            {
              "advised": true,
              "goto": "s10",
              "id": "agree",
              "label": "Both agree to a stated split"
            },
            {
              "goto": "s12",
              "id": "disagree",
              "label": "Parents disagree or one is unreachable"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "office-manager",
          "title": "Do both parents agree in writing to split the bill?"
        },
        {
          "detail": "Have both parents sign the practice's guarantor split form stating the percentage each will pay and confirming both understand the practice bills each parent separately for their share.",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Get a signed split-guarantor agreement from both parents"
        },
        {
          "detail": "Enter two guarantor records tied to the same patient, each carrying its agreed percentage of every future charge, and confirm statements will go to both addresses.",
          "id": "s11",
          "kind": "step",
          "role": "billing",
          "title": "Configure the split billing entries"
        },
        {
          "detail": "Without agreement or a court order, bill the parent who authorized the treatment; note in the account that a second parent disputes responsibility so the office recognizes the context if they call.\n\nWhy: The parent who consented to treatment is the one who contracted for it; the practice does not withhold care or delay billing while parents negotiate.",
          "id": "s12",
          "kind": "step",
          "role": "billing",
          "title": "Bill the parent who signed treatment consent as sole guarantor",
          "why": "The parent who consented to treatment is the one who contracted for it; the practice does not withhold care or delay billing while parents negotiate."
        },
        {
          "detail": "Is the disputing parent contacting the office repeatedly or making threats about payment/legal action?",
          "forks": [
            {
              "advised": true,
              "goto": "s14",
              "id": "escalate",
              "label": "Escalate to office manager for direct handling"
            },
            {
              "goto": "s6",
              "id": "routine",
              "label": "No escalation needed"
            }
          ],
          "id": "s13",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is the disputing parent contacting the office repeatedly or making threats about payment/legal action?"
        },
        {
          "detail": "Office manager, not front desk, becomes the sole point of contact for the disputing parent going forward and documents every call.\n\nWhy: Repeated or escalating disputes are a supervisor-level financial and risk matter, not a front-desk one.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Supervisor takes over direct communication.",
            "role": "office-manager",
            "type": "licensed"
          },
          "id": "s14",
          "kind": "gate",
          "role": "office-manager",
          "title": "Supervisor takes over direct communication",
          "why": "Repeated or escalating disputes are a supervisor-level financial and risk matter, not a front-desk one."
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Split guarantor and divorced-parent financial responsibility — Two parents dispute who pays for a minor's treatment, or a court order assigns responsibility.",
      "title": "Split guarantor and divorced-parent financial responsibility",
      "trigger": "Two parents dispute who pays for a minor's treatment, or a court order assigns responsibility",
      "trigger_kind": "event",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "statute",
          "label": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)",
          "repaired": {
            "action": "reduce",
            "evidence": "'A dental membership plan that charges a fee for access to discounted services is, by definition, a Discount Medical Plan (DMP)... Regulatory requirements for DMPs vary from state to state, and can include written plan agreements, compliant marketing materials and disclaimers, specific member communications, surety bonds, and cancellation rights.'",
            "ticket": "PROT-017",
            "was": {
              "source": "State discount-medical-plan / dental membership plan statutes (varies by state)",
              "url": null
            }
          },
          "source": "State discount-medical-plan / dental membership plan statutes — govern in-house membership/discount-plan enrollment, required disclosures, and cancellation/proration terms (does not reach general treatment-plan presentation, financial estimates, or third-party financing)"
        },
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 45,
      "frequency": "annual",
      "id": "tpf-019",
      "kind": "operational",
      "materials": [
        "current signed payer/PPO contracts",
        "state discount-medical-plan or dental membership statute reference",
        "proposed discount program terms",
        "advertising copy draft"
      ],
      "needs_ack_review": true,
      "review_status": "draft_unreviewed",
      "roles": [
        "practice-owner",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 3,
      "steps": [
        {
          "detail": "The two paths share the same underlying risk (a discount that conflicts with a payer's fee-parity clause) but start from different triggers.",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "new-discount",
              "label": "Creating or changing a standing discount"
            },
            {
              "goto": "s4",
              "id": "contract-check",
              "label": "Periodic payer contract review"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "office-manager",
          "title": "Is this a new/changed discount program or a periodic payer contract check?"
        },
        {
          "detail": "Write the discount percentage, eligible categories (senior, cash-pay, military, staff family, etc.), and which procedures it applies to.",
          "id": "s2",
          "kind": "step",
          "role": "office-manager",
          "title": "Draft the proposed discount terms"
        },
        {
          "detail": "Confirm whether the state treats an in-office discount program as a regulated 'discount medical/dental plan' requiring registration or specific disclosures — this varies by state and changes periodically.\n\nWhy: Some states require a licensed discount-plan filing once a program is advertised broadly rather than offered case-by-case.",
          "id": "s3",
          "kind": "step",
          "role": "office-manager",
          "title": "Check the practice's state discount-plan statute",
          "why": "Some states require a licensed discount-plan filing once a program is advertised broadly rather than offered case-by-case."
        },
        {
          "detail": "Gather the complete, current contract text (not a summary) for each insurer the practice is in-network with.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Pull every currently signed payer/PPO contract"
        },
        {
          "detail": "For each contract: (1) search for language requiring the practice's discounted cash fee to be offered to that payer's members too, (2) note any clause limiting discounts to specific categories (e.g. financial hardship only), (3) note any required advance notice to the payer before offering a new discount, (4) flag any contract with no such clause as unrestricted.",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Check each contract for a fee-parity / most-favored-nation clause"
        },
        {
          "detail": "Does any payer contract conflict with the proposed or existing discount?",
          "forks": [
            {
              "advised": true,
              "goto": "s7",
              "id": "no-conflict",
              "label": "No conflicting clause found"
            },
            {
              "goto": "s11",
              "id": "conflict",
              "label": "A fee-parity or restriction clause conflicts"
            }
          ],
          "id": "s6",
          "kind": "fork",
          "role": "billing",
          "title": "Does any payer contract conflict with the proposed or existing discount?"
        },
        {
          "detail": "Practice owner (or an explicitly delegated approver) reviews the drafted discount terms and the contract-check outcome and approves the program for publication, even when billing found no fee-parity conflict — this is a lightweight notify/approve step, not a full re-review.\n\nWhy: A standing, externally advertised discount can carry state discount-plan filing exposure (see the state-statute check above) regardless of whether a conflict was found in the payer contracts, so the role named as owner of this protocol should see every program before it goes live, not only the conflicted ones.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews the no-conflict finding before the program is published.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s7",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews the no-conflict finding before the program is published",
          "why": "A standing, externally advertised discount can carry state discount-plan filing exposure (see the state-statute check above) regardless of whether a conflict was found in the payer contracts, so the role named as owner of this protocol should see every program before it goes live, not only the conflicted ones."
        },
        {
          "detail": "Post the final terms internally (fee schedule, front-desk script) and, if advertised externally, confirm the ad copy matches the finalized eligibility and does not overstate the discount.",
          "id": "s8",
          "kind": "step",
          "role": "office-manager",
          "title": "Finalize and publish the discount program"
        },
        {
          "detail": "File the finalized discount terms and the payer-contract review outcome in the practice's compliance file for the next scheduled review.\n\nRecord: Discount terms, eligibility, statute check outcome, list of contracts reviewed, any conflicts found and how resolved, and the date of next scheduled review, filed in the practice's compliance file.",
          "id": "s9",
          "kind": "step",
          "role": "office-manager",
          "title": "Document the discount program and the contract check"
        },
        {
          "detail": "Discount program / contract review closed",
          "id": "s10",
          "kind": "step",
          "role": "office-manager",
          "title": "Discount program / contract review closed"
        },
        {
          "detail": "Practice owner decides whether to narrow the discount's eligibility, exclude patients covered by the conflicting payer, renegotiate the contract clause, or drop the discount plan entirely.\n\nWhy: A discount that breaches a signed payer contract's fee-parity clause is a contract and revenue risk that only the practice owner can accept or decline.",
          "gate": {
            "ack": "I confirm I have completed this step as written: Practice owner reviews the conflict before proceeding.",
            "role": "practice-owner",
            "type": "licensed"
          },
          "id": "s11",
          "kind": "gate",
          "role": "practice-owner",
          "title": "Practice owner reviews the conflict before proceeding",
          "why": "A discount that breaches a signed payer contract's fee-parity clause is a contract and revenue risk that only the practice owner can accept or decline."
        },
        {
          "detail": "Update the eligibility rules, exclusions, or advertising copy to resolve the flagged conflict before the program goes live.",
          "id": "s12",
          "kind": "step",
          "role": "office-manager",
          "title": "Adjust the discount terms per the owner's decision"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "Standing discount programs (senior, cash, military) and payer contract checks — The practice creates or advertises a standing discount, or a payer contract's fee-parity clause is reviewed.",
      "title": "Standing discount programs (senior, cash, military) and payer contract checks",
      "trigger": "The practice creates or advertises a standing discount, or a payer contract's fee-parity clause is reviewed",
      "trigger_kind": "periodic",
      "version": "1.0.0"
    },
    {
      "citations": [
        {
          "kind": "generic",
          "label": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced",
          "source": "Generic functional equivalent for case presentation (why, what, when, cost, options) — no case-acceptance consultancy system reproduced"
        }
      ],
      "class": "case-acceptance-financial-communication",
      "department": "front-office",
      "duration_min": 15,
      "frequency": "per-use",
      "id": "tpf-020",
      "kind": "operational",
      "materials": [
        "HSA/FSA eligible-expense reference list",
        "gift certificate template with terms",
        "prepaid deposit receipt form",
        "point-of-sale card terminal"
      ],
      "review_status": "draft_unreviewed",
      "roles": [
        "front-desk",
        "billing",
        "office-manager"
      ],
      "schema": "protocol_v1",
      "severity": 2,
      "steps": [
        {
          "detail": "What is the patient trying to do?",
          "forks": [
            {
              "advised": true,
              "goto": "s2",
              "id": "hsa-fsa",
              "label": "Pay with an HSA/FSA card"
            },
            {
              "goto": "s6",
              "id": "gift-cert",
              "label": "Buy a gift certificate"
            },
            {
              "goto": "s7",
              "id": "deposit",
              "label": "Prepay a deposit for a large case"
            }
          ],
          "id": "s1",
          "kind": "fork",
          "role": "front-desk",
          "title": "What is the patient trying to do?"
        },
        {
          "detail": "Check the procedure against the practice's eligible-expense reference: procedures with a documented medical/dental necessity (fillings, crowns for decay, extractions, orthodontics for a functional bite issue) are generally eligible; purely cosmetic procedures (teeth whitening with no medical need) generally are not.\n\nWhy: Charging an ineligible cosmetic service to an HSA/FSA card can create a tax problem for the patient and a compliance record request from their plan administrator later — the practice should not guess wrong on their behalf.",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "eligible",
              "label": "Clearly eligible (restorative/functional)"
            },
            {
              "goto": "s8",
              "id": "unclear",
              "label": "Cosmetic or unclear eligibility"
            }
          ],
          "id": "s2",
          "kind": "fork",
          "role": "billing",
          "title": "Is the procedure an HSA/FSA-eligible medical expense?",
          "why": "Charging an ineligible cosmetic service to an HSA/FSA card can create a tax problem for the patient and a compliance record request from their plan administrator later — the practice should not guess wrong on their behalf."
        },
        {
          "detail": "Run the card through the terminal for the exact procedure amount and provide an itemized receipt naming the procedure — most HSA/FSA administrators require the itemized description, not just the amount.",
          "id": "s3",
          "kind": "step",
          "role": "front-desk",
          "title": "Process the HSA/FSA card like any other card payment"
        },
        {
          "detail": "File the payment type, amount and applicable terms in the patient account and the practice's payments log.\n\nRecord: Payment type (HSA/FSA card, gift certificate, or deposit), amount, procedure or plan it applies to, and any terms disclosed (refund window, expiration), filed in the patient account and the practice's payments log.",
          "id": "s4",
          "kind": "step",
          "role": "billing",
          "title": "Record the transaction against the correct ledger category"
        },
        {
          "detail": "Payment transaction closed",
          "id": "s5",
          "kind": "step",
          "role": "billing",
          "title": "Payment transaction closed"
        },
        {
          "detail": "Complete the gift certificate template with the dollar value, purchaser name, recipient (if named), issue date, and any expiration or transfer terms per the practice's policy; collect payment and give the purchaser their copy.",
          "id": "s6",
          "kind": "step",
          "role": "front-desk",
          "title": "Issue the gift certificate"
        },
        {
          "detail": "Collect the deposit amount, issue a receipt naming the treatment plan it is held against, and state the refund policy (window and conditions) in writing to the patient before taking the payment.\n\nWhy: Stating the refund terms up front, before money changes hands, prevents disputes if the patient's plan changes or they don't proceed.",
          "id": "s7",
          "kind": "step",
          "role": "billing",
          "title": "Take the prepaid treatment deposit",
          "why": "Stating the refund terms up front, before money changes hands, prevents disputes if the patient's plan changes or they don't proceed."
        },
        {
          "detail": "Explain plainly that the practice cannot confirm this specific procedure is HSA/FSA-eligible, and that using the card for an ineligible expense is the cardholder's responsibility to their plan, not the practice's determination to make.\n\nWhy: The practice processes the payment the patient authorizes; it does not adjudicate tax eligibility on the patient's behalf.",
          "id": "s8",
          "kind": "step",
          "role": "front-desk",
          "title": "Tell the patient the eligibility is unclear and let them decide",
          "why": "The practice processes the payment the patient authorizes; it does not adjudicate tax eligibility on the patient's behalf."
        },
        {
          "detail": "Does the patient still want to use the HSA/FSA card?",
          "forks": [
            {
              "advised": true,
              "goto": "s3",
              "id": "proceed",
              "label": "Patient proceeds with the card"
            },
            {
              "goto": "s10",
              "id": "alt-payment",
              "label": "Patient chooses a different payment method"
            }
          ],
          "id": "s9",
          "kind": "fork",
          "role": "front-desk",
          "title": "Does the patient still want to use the HSA/FSA card?"
        },
        {
          "detail": "Take payment by the patient's chosen alternate method (card, cash, or an already-established payment plan) and provide a standard receipt.",
          "id": "s10",
          "kind": "step",
          "role": "front-desk",
          "title": "Process the alternate payment method"
        }
      ],
      "subclass": "treatment-presentation-and-financial-arrangements",
      "summary": "HSA/FSA card payments, gift certificates and prepaid treatment deposits — A patient pays with an HSA/FSA card for a cosmetic service, buys a gift certificate, or prepays for a large case.",
      "title": "HSA/FSA card payments, gift certificates and prepaid treatment deposits",
      "trigger": "A patient pays with an HSA/FSA card for a cosmetic service, buys a gift certificate, or prepays for a large case",
      "trigger_kind": "routine",
      "version": "1.0.0"
    }
  ],
  "review_status_honesty": "Every record is draft_unreviewed until a licensed dentist clears it in HITL Rounds (the protocol_reviews / protocol_reviews_ops queues). Presence in this export is a structural-validation and public-domain-citation claim, never a clinical-review claim.",
  "schema": "protocol_export_graph_v1"
}