Specialty Clinic Procedure Map

Per-clinic procedure complexity tiers, extra input fields, OR-like feature requirements, and standing order applicability.

Architecture Summary

Every OPD specialty clinic uses the same DayProcedureOrder miniapp (mounted via DynamicContentRenderer with clinicKey). The procedure catalog comes from clinic-configs.ts. When ordered, it hits the existing procedureRequest backend (April 2025) with ROUTINE / URGENT / STAT priority. The procedure then flows through the procedure_day_queue system with configurable OR-like features per department.

Existing Building Blocks (already built)

System	Location	What It Does
DayProcedureOrder miniapp	web/packages/miniapps/day-procedure-order/	Order UI with priority picker, per-clinic catalog
procedureRequest API	POST v2/medication/procedureRequests	Backend order creation (MongoDB)
procedure_day_queue table	migration 079	Tracks each procedure through phases with timestamps
ProcedureFeatureConfig	procedureWorkflowConfig.types.ts	Per-department toggle for 10 OR-style features
or_intraop_counts table	migration 080	JSONB sponge/instrument/needle counting
Standing Orders	web/packages/medical-kit/src/order/components/standing-order/	RRULE-based recurring orders for all order types
EndoscopySafetyChecklist	periops-kit/src/endoscopy/	Reference implementation of procedure-specific safety checklist
PACU Handoff miniapp	web/packages/miniapps/pacu-handoff/	Recovery scoring, vitals, drains, lines
OperativeNote miniapp	web/packages/miniapps/operative-note/	CountSet, TeamMember, procedure documentation
department_queues → orchestrator	encounter-orchestrator/index.ts	Aggregates completion → medical worklist green dot

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Procedure Complexity Tiers

Tier 1 — Simple (OPD-only, no OR features)

Nurse calls patient → procedure done at bedside/chair → mark complete. No sign-in/time-out/sign-out needed.

ProcedureFeatureConfig: all features enabled: false (default)

Tier 2 — Moderate (sign-in + team + basic safety)

Procedure room with dedicated space. Needs patient ID verification, team assignment, basic consent check. No full WHO checklist or counting.

ProcedureFeatureConfig:

• sign_in: enabled, required
• surgical_team: enabled (with reduced roles — e.g. ['proceduralist', 'assistant'])
• Everything else OFF

Tier 3 — OR-Like (full WHO safety checklist + counting)

Invasive procedure requiring sterile field, instrument counting, specimen tracking, and recovery monitoring. Full OR workflow minus the general anesthesia pathway.

ProcedureFeatureConfig:

• sign_in: enabled, required
• time_out: enabled, required
• sign_out: enabled, required
• surgical_team: enabled, required (full 5-role roster)
• intra_op: enabled
• recovery: enabled (for sedation cases)
• par_score: enabled (for sedation/GA cases)

Tier 4 — Full OR (existing surgical OR — not covered here)

Standard operating room workflow — already fully implemented.

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Per-Clinic Procedure Matrix

GI Endoscopy (gi-endoscopy) — Tier 3

Procedure	Code	Extra Fields	OR Features	Standing Order
EGD	GI-EGD	sedationType (conscious/deep/none), scopeSerial, roomNumber	Sign-In, Time-Out, Sign-Out, Team (proceduralist + assistant + anesthetist + scrub_nurse), Recovery, Intra-Op	No
Colonoscopy	GI-COLON	sedationType, scopeSerial, roomNumber, bowelPrepQuality (Boston scale 0-9)	Same as EGD	No
ERCP	GI-ERCP	sedationType, scopeSerial, roomNumber, fluoroscopyTime, contrastVolume	Same + counting (guidewires, stents)	No
Endoscopic Biopsy	GI-BIOPSY	biopsySite[], biopsyCount, specimenJars	Sign-In, Time-Out (specimen tracking), Sign-Out	No
Polypectomy	GI-POLYPECTOMY	polypCount, polypSizes[], technique (cold snare/hot snare/EMR)	Same as EGD + counting (snares, clips)	No

Notes: GI Endoscopy already has EndoscopySafetyChecklist component with Aldrete recovery scoring. Endoscope serial tracking for infection control. Video/image capture integration (PACS).

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Hemodialysis (hemodialysis) — Tier 2 + Continuous Monitoring

Procedure	Code	Extra Fields	OR Features	Standing Order
HD Session	HD-SESSION	machineNumber, accessType (AVF/AVG/catheter), accessSite, dryWeight, targetUF, dialysateK, dialysateNa, dialysateCa, anticoagulant (heparin/LMWH/none), heparinDose, bloodFlowRate, dialysateFlowRate, preWeight, postWeight, preBP, postBP	Sign-In (patient ID + access check), Team (proceduralist + nurse)	Yes — 3x/week RRULE (FREQ=WEEKLY;BYDAY=MO,WE,FR)
CRRT/SLED	HD-CRRT	machineNumber, accessType, mode (CVVH/CVVHD/CVVHDF/SLED), effluent_rate, bloodFlowRate, anticoagulant, citrateDose	Sign-In, Team (proceduralist + nurse + ICU nurse), Continuous vitals	No (ICU-specific)
Plasmapheresis	HD-PLASMA	machineNumber, accessType, replacementFluid (albumin/FFP), volumeExchanged, cycleCount	Sign-In, Team	No
AVF/AVG Care	HD-AVF-CARE	accessType, accessSite, thrillPresent, bruitPresent, signOfInfection	None (Tier 1)	Yes — monthly (FREQ=MONTHLY)

Notes: HD Session is the most common standing order in the system. Continuous recording (every 30-60 min) for vitals, UF, BP during session. Machine integration API for realtime monitoring.

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Psychiatry (psychiatry) — Tier 2 (ECT) / Tier 1 (therapy)

Procedure	Code	Extra Fields	OR Features	Standing Order
ECT	PSY-ECT	sessionNumber, stimulusEnergy (mC), stimulusDuration, seizureDuration (sec), seizureQuality, anestheticAgent, muscleRelaxant, oxygenSat, recoveryMinutes, sideEffects[]	Sign-In (consent + NPO), Time-Out (electrode placement), Team (psychiatrist + anesthesiologist + nurse), Recovery, PAR Score	Yes — typically 3x/week for 6-12 sessions (FREQ=WEEKLY;BYDAY=MO,WE,FR;COUNT=12)
TMS	PSY-TMS	sessionNumber, coilPosition (DLPFC L/R), stimulusIntensity (% MT), pulseFrequency (Hz), pulseCount, motorThreshold	Sign-In (seizure history check)	Yes — daily x20-30 sessions (FREQ=WEEKLY;BYDAY=MO,TU,WE,TH,FR;COUNT=30)
CBT	PSY-CBT	sessionNumber, sessionTopic, homeworkAssigned, phq9Score, gad7Score	None (Tier 1)	Yes — weekly x8-16 sessions (FREQ=WEEKLY;COUNT=16)

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Family Medicine (family-medicine) — Tier 1

Procedure	Code	Extra Fields	OR Features	Standing Order
Minor Wound Care	FM-WOUND	woundLocation, woundSize (cm), woundType (laceration/abrasion/burn), closureMethod (suture/staple/glue/steri-strip), sutureType, sutureCount, anestheticUsed, tetanusStatus	Sign-In (if suturing)	No
Joint Injection	FM-INJECT	injectionSite, laterality (L/R/bilateral), medication, dose, volume, needleGauge, technique (palpation/US-guided)	None	Yes — for series (e.g. 3 injections q2w: FREQ=WEEKLY;INTERVAL=2;COUNT=3)
Pap Smear	FM-PAP	specimenType (conventional/LBC), adequacy, cervicalAppearance, iudPresent	None	Yes — annual screening (FREQ=YEARLY)

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Palliative Care (palliative-care) — Tier 2

Procedure	Code	Extra Fields	OR Features	Standing Order
Nerve Block	PAL-NERVE-BLOCK	blockType (epidural/intercostal/celiac/stellate), laterality, medication, dose, volume, needleGauge, guidance (US/fluoro/blind), preVAS, postVAS	Sign-In, Time-Out (site verification), Team (proceduralist + nurse)	Yes — for series
Paracentesis	PAL-PARACENTESIS	indication, volume_drained (mL), fluidAppearance, specimenSent (cell count/cytology/culture), albumin_given	Sign-In, Team	No
Thoracentesis	PAL-THORACENTESIS	indication, laterality, volume_drained, fluidAppearance, specimenSent, postCXR	Sign-In, Team	No

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Elderly Clinic (elderly) — Tier 1

Procedure	Code	Extra Fields	OR Features	Standing Order
Fall Prevention Rehab	ELD-FALLS-REHAB	sessionNumber, exerciseProtocol, bergBalanceScore, tugTime (sec)	None	Yes — 2x/week x12w (FREQ=WEEKLY;BYDAY=TU,TH;COUNT=24)
Cognitive Stimulation	ELD-COGNITIVE-STIM	sessionNumber, activityType, preMoCA, postMoCA	None	Yes — weekly x14 (FREQ=WEEKLY;COUNT=14)
IV Nutrition	ELD-NUTRITION-IV	formula, volume, infusionRate, duration, accessSite	Sign-In (patient ID + allergies)	Yes — as prescribed

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Holter Monitoring (holter-monitoring) — Tier 1 + Device Tracking

Procedure	Code	Extra Fields	OR Features	Standing Order
Holter Fitting	HOLTER-FIT	deviceSerial, leadPlacement, skinPrep, signalQuality	None	No
Holter Removal	HOLTER-REMOVE	deviceSerial, recordingHours, artifactPercent, diaryReturned	None	No
Event Recorder	HOLTER-EVENT	deviceSerial, activationType (auto/manual/both), monitoringDays	None	No

Notes: Uses device_monitoring_cases table for multi-day lifecycle. deviceMonitoringBridge.ts detects these codes and routes to the Holter fitting workflow. Two-visit pattern (attach + return) tracked via deviceQueueService.ts.

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ABP Monitoring (abp) — Tier 1 + Device Tracking

Procedure	Code	Extra Fields	OR Features	Standing Order
ABP Fitting	ABP-FIT	deviceSerial, arm (L/R), cuffSize (S/M/L/XL), baselineSystolic, baselineDiastolic, intervalDay (min), intervalNight (min)	None	No
ABP Removal	ABP-REMOVE	deviceSerial, readingsTotal, readingsValid, validPercent	None	No

Notes: Same two-visit device tracking pattern as Holter. Dipping analysis (dipper/non-dipper/reverse-dipper) computed from results.

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Respiratory / Thoracic (respiratory-thoracic) — Mixed Tiers

Procedure	Code	Extra Fields	OR Features	Standing Order
PFT / Spirometry	RESP-PFT	fvc, fev1, fev1FvcRatio, dlco, preBronchodilator (bool), postBronchodilator (bool), postFev1Change (%), interpretation	None (Tier 1)	Yes — annual for COPD/asthma (FREQ=YEARLY)
6MWT	RESP-6MWT	distanceMeters, preSpO2, nadirSpO2, preHR, peakHR, borgDyspnea (0-10), borgFatigue (0-10), supplementalO2	None (Tier 1)	Yes — q6mo for ILD/PH (FREQ=MONTHLY;INTERVAL=6)
Bronchoscopy	RESP-BRONCH	sedationType, scopeSerial, lavageSite, lavageVolume, biopsySite[], biopsyCount, findings	Sign-In, Time-Out, Sign-Out, Team (proceduralist + nurse + anesthetist), Recovery (Tier 3)	No
Pleural Tap	RESP-PLEURAL-TAP	laterality, volumeDrained, fluidAppearance, specimenSent, guidance (US/blind), postCXR	Sign-In, Team (Tier 2)	No
Nebulizer	RESP-NEBULIZER	medication, dose, duration, preSpO2, postSpO2, prePEFR, postPEFR	None (Tier 1)	Yes — per acute episode

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Antenatal Care (antenatal-care) — Mixed Tiers

Procedure	Code	Extra Fields	OR Features	Standing Order
Obstetric US	ANC-US	gestationalAge, fetalPosition, fetalHeartRate, amnioticFluidIndex, placentaLocation, estimatedFetalWeight, biophysicalProfile	None (Tier 1)	Yes — per trimester schedule
NST	ANC-NST	gestationalAge, baselineHR, variability, accelerations, decelerations, interpretation (reactive/non-reactive), duration	None (Tier 1)	Yes — weekly after 32w (FREQ=WEEKLY)
Amniocentesis	ANC-AMNIO	gestationalAge, indication, needleGauge, fluidVolume, fluidColor, specimenSent (karyotype/FISH/AFP), guidance (US)	Sign-In (consent + Rh status), Time-Out, Team (MFM + nurse) (Tier 2-3)	No
GDM OGTT	ANC-GDM-OGTT	gestationalAge, fastingGlucose, 1hrGlucose, 2hrGlucose, 3hrGlucose, glucoseLoad (50g/75g/100g), interpretation	None (Tier 1)	No

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Diabetes Registry (diabetes-registry) — Tier 1

Procedure	Code	Extra Fields	OR Features	Standing Order
Diabetic Foot Care	DM-FOOT-CARE	footSide (L/R/both), nailTrimming, callousRemoval, woundPresent, woundGrade (Wagner 0-5), monofilamentScore (0-10), pulsesPalpable	None	Yes — monthly for high-risk (FREQ=MONTHLY)
ABI Test	DM-ABI	abiLeft, abiRight, interpretation (normal/mild/moderate/severe PAD), toeBrachialIndex	None	Yes — annual (FREQ=YEARLY)
Fundus Photography	DM-FUNDUS	eyeSide (L/R/both), pupilDilation, retinaGrade (none/mild NPDR/moderate/severe/PDR), maculaEdema, referToOphth	None	Yes — annual (FREQ=YEARLY)
Insulin Pump	DM-INSULIN-PUMP	pumpModel, pumpSerial, infusionSite, basalRate, bolusCalculator, sensorConnected, targetRange	None	No

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Vaccination (vaccination) — Tier 1

Procedure	Code	Extra Fields	OR Features	Standing Order
Vaccination	VACC-INJECT	vaccineName, vaccineBrand, lotNumber, expiryDate, site (deltoid L/R, thigh L/R), route (IM/SC/ID/oral), dose (mL), doseNumber (1st/2nd/3rd/booster), coldChainTemp	None	Yes — per schedule (e.g. HBV 0-1-6mo: FREQ=MONTHLY;BYMONTH=1;COUNT=3 with custom dtstart)
Post-Vax Observation	VACC-OBSERVE	observationStartTime, observationEndTime, adverseReaction (none/local/systemic), reactionDetails, anaphylaxisKit	None	No
Skin Test	VACC-SKIN-TEST	testType (Mantoux/PPD/allergy panel), antigen, site, readingAt48h (mm induration), interpretation	None	No

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Palliative Care Center (palliative-care other_service) — Tier 1-2

Procedure	Code	Extra Fields	OR Features	Standing Order
Symptom Management	PC-SYMPTOM-MGMT	painVAS, nausea, dyspnea, delirium, agitation, esasTotal, medicationsGiven[], route	None	Yes — per visit schedule
Pleural Drainage	PC-PLEURAL-DRAIN	Same as PAL-THORACENTESIS	Sign-In, Team (Tier 2)	No
Family Meeting	PC-FAMILY-MEETING	attendees[], decisionsReached, acpUpdated, codeStatus, goalOfCare	None	No

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Home Visit (home-visit) — Tier 1

Procedure	Code	Extra Fields	OR Features	Standing Order
Home Wound Care	HV-WOUND-CARE	woundLocation, woundSize, woundStage, dressingType, healingProgress	None	Yes — 2-3x/week (FREQ=WEEKLY;BYDAY=MO,WE,FR)
Home IV Infusion	HV-IV-INFUSION	medication, volume, rate, accessType, accessSite, duration	None	Yes — per schedule
Home Catheter Change	HV-CATHETER	catheterType (Foley/suprapubic), catheterSize (Fr), balloonVolume, urineAppearance, residualVolume	None	Yes — monthly (FREQ=MONTHLY)

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Home Isolation (home-isolation) — Tier 1

Procedure	Code	Extra Fields	OR Features	Standing Order
Teleconsultation	HI-TELECONSULT	platform (video/voice/chat), chiefComplaint, assessment, plan, followUpDays	None	Yes — daily during isolation (FREQ=DAILY)
Home Vitals Check	HI-VITALS-CHECK	temperature, heartRate, bloodPressure, spO2, respiratoryRate, alertLevel (green/yellow/red)	None	Yes — daily (FREQ=DAILY)

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Standing Order Summary

Clinic	Procedures Using Standing Orders	Typical RRULE
Hemodialysis	HD Session, AVF Care	3x/week, monthly
Psychiatry	ECT, TMS, CBT	3x/week x12, daily x30, weekly x16
Family Medicine	Joint Injection, Pap Smear	q2w x3, yearly
Elderly	Falls Rehab, Cognitive Stim, IV Nutrition	2x/week x24, weekly x14
Respiratory	PFT, 6MWT, Nebulizer	yearly, q6mo
ANC	Obstetric US, NST	per trimester, weekly after 32w
Diabetes	Foot Care, ABI, Fundus Photo	monthly, yearly
Vaccination	Vaccination series	per EPI schedule
Home Visit	Wound Care, IV, Catheter	2-3x/week, monthly
Home Isolation	Teleconsult, Vitals Check	daily
Palliative	Symptom Management	per visit

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OR Feature Requirement Summary

Clinic	Sign-In	Time-Out	Sign-Out	Team	Intra-Op	Recovery	PAR	Counting
GI Endoscopy	Required	Required	Required	Full 4-role	Yes	Yes (Aldrete)	Yes	Yes (guidewires, clips, snares)
Hemodialysis	Required	—	—	2-role	—	—	—	—
Psychiatry (ECT)	Required	Required	—	3-role	—	Yes	Yes	—
Psychiatry (TMS/CBT)	—	—	—	—	—	—	—	—
Family Medicine	Optional	—	—	—	—	—	—	—
Palliative (blocks)	Required	Required	—	2-role	—	—	—	—
Palliative (taps)	Required	—	—	2-role	—	—	—	—
Respiratory (Bronch)	Required	Required	Required	3-role	—	Yes	Yes	Yes (biopsy forceps)
Respiratory (Pleural)	Required	—	—	2-role	—	—	—	—
ANC (Amniocentesis)	Required	Required	—	2-role	—	—	—	—
All others	—	—	—	—	—	—	—	—

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Implementation Plan

Phase 1 — Extend Procedure Type with Extra Fields

1. Add extraFields to SpecialtyClinicDayProcedure type:

   interface ProcedureExtraField {
     key: string;
     labelTh: string;
     labelEn: string;
     type: 'text' | 'number' | 'select' | 'boolean' | 'date' | 'time' | 'laterality';
     options?: { value: string; labelTh: string; labelEn: string }[];
     required?: boolean;
     unit?: string;
     min?: number;
     max?: number;
   }
   

2. Add extraFields: ProcedureExtraField[] to each procedure in clinic-configs.ts
3. Update DayProcedureOrder NewProcedureOrderPanel to dynamically render extra fields
4. Store extra field values in procedureRequest.metadata JSONB

Phase 2 — Wire OR Feature Toggles per Clinic

1. Seed procedure_workflow_config rows for each clinic department:
   • GI Endoscopy: Tier 3 (full safety checklist)
   • Hemodialysis: Tier 2 (sign-in + team)
   • Psychiatry: Tier 2 for ECT, Tier 1 for CBT
   • Respiratory: Tier 3 for Bronchoscopy, Tier 1 for PFT
   • etc.
2. The existing ProcedureWorkflowConfigService already resolves per-department — no new code needed, just seed data

Phase 3 — Standing Order Integration

1. Add “Convert to Standing Order” button in DayProcedureOrder when priority = ROUTINE
2. Pre-fill the CreateStandingOrderInput from the procedure:
   • order_type: 'procedure'
   • order_template: procedure code + extra field values
   • rrule: suggest based on clinic defaults (see table above)
   • activation_mode: 'confirm' (nurse confirms each occurrence)
3. Show StandingOrderBadge on the patient profile procedure tab

Phase 4 — Generalize Safety Checklist Component

1. Abstract EndoscopySafetyChecklist into ``
2. Each clinic’s custom items come from ProcedureFeatureConfig.fieldOverrides.items[]
3. Reuse existing sign_in, time_out, sign_out phase infrastructure

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File References

File	Purpose
web/packages/miniapps/specialty-clinics/clinic-configs.ts	Per-clinic procedure catalog
web/packages/miniapps/specialty-clinics/types.ts	SpecialtyClinicDayProcedure type
web/packages/miniapps/day-procedure-order/index.tsx	Order UI miniapp
web/src/services/procedure-workflow-config/procedureWorkflowConfig.types.ts	OR feature toggle system
web/packages/medical-kit/src/order/components/standing-order/interface.ts	Standing order types
web/packages/periops-kit/src/endoscopy/components/EndoscopySafetyChecklist.tsx	Reference safety checklist
web/packages/miniapps/operative-note/types.ts	CountSet, TeamMember types
web/packages/miniapps/pacu-handoff/	Recovery/PACU handoff
infrastructure/medbase/migrations/079_procedure_day_queue.sql	Phase tracking table
infrastructure/medbase/migrations/080_or_intraop_counts.sql	Counting table
infrastructure/medbase/functions/encounter-orchestrator/index.ts	dept_type rollup (holter/abp → procedure)
web/packages/periops-kit/src/shared/deviceMonitoringBridge.ts	Device procedure code detection
web/packages/periops-kit/src/shared/deviceQueueService.ts	Device visit queue integration